EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy
Objective: Studies of kidney injury following use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections among patients with diabetic retinopathy have mixed results and are limited by sample size and study design. Our objective was to determine whether intravitreal use of ant...
- Autores:
-
Chen, NC
Kane-Gill, S
Suh, K
- Tipo de recurso:
- Article of investigation
- Fecha de publicación:
- 2022
- Institución:
- Corporación Universidad de la Costa
- Repositorio:
- REDICUC - Repositorio CUC
- Idioma:
- eng
- OAI Identifier:
- oai:repositorio.cuc.edu.co:11323/10722
- Acceso en línea:
- https://hdl.handle.net/11323/10722
https://repositorio.cuc.edu.co/
- Palabra clave:
- Diabetic retinopathy
Vascular Endothelial Growth Factor (VEGF)
Kidney
- Rights
- embargoedAccess
- License
- Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)
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dc.title.eng.fl_str_mv |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
title |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
spellingShingle |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy Diabetic retinopathy Vascular Endothelial Growth Factor (VEGF) Kidney |
title_short |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
title_full |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
title_fullStr |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
title_full_unstemmed |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
title_sort |
EPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathy |
dc.creator.fl_str_mv |
Chen, NC Kane-Gill, S Suh, K |
dc.contributor.author.none.fl_str_mv |
Chen, NC Kane-Gill, S Suh, K |
dc.subject.proposal.eng.fl_str_mv |
Diabetic retinopathy Vascular Endothelial Growth Factor (VEGF) Kidney |
topic |
Diabetic retinopathy Vascular Endothelial Growth Factor (VEGF) Kidney |
description |
Objective: Studies of kidney injury following use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections among patients with diabetic retinopathy have mixed results and are limited by sample size and study design. Our objective was to determine whether intravitreal use of anti-VEGF agents was associated with adverse kidney outcomes compared to treatment with traditional laser photocoagulations. Methods: Adult patients with diabetic retinopathy and use of intravitreal anti-VEGF injections or laser photocoagulation were identified from January 2011, through December 2020 in large nationally representative database of administrative and electronic health record information for commercially insured and Medicare/Medicaid Advantage patients. Outcomes assessed included diagnosis of new chronic kidney disease (CKD), worsening CKD, and a composite endpoint of hospitalization or death using survival analyses. We applied inverse probability treatment weighting using propensity scores and adjusted for demographics, comorbidities, CKD stages at baseline and number of antidiabetic medications. Results: A total of 2,566 patients met the inclusion criteria, with 1,392 patients receiving intravitreal anti-VEGF injections and 1,174 patients receiving laser photocoagulation. Patients in the anti-VEGF group had a 33% higher hazard for newly developed CKD compared to patients in the laser group after adjustment (95% CI: 1.10, 1.60). There was no significant difference in worsening of pre-existing CKD in these two groups (HR=0.93; 95% CI: 0.77, 1.33). Patients treated with intravitreal antiVEGF injections had significantly higher hazards for hospitalizations and mortality compared to those treated with laser photocoagulation (HR=1.17; 95% CI: 1.04, 1.31). Conclusions: While use of anti-VEGF intravitreal injections was not associated with worsening CKD compared to laser photocoagulation, patients without pre-existing CKD had a higher risk of developing newly diagnosed CKD. These results continue to question the effects anti-VEGF injections have on adverse kidney outcomes. |
publishDate |
2022 |
dc.date.issued.none.fl_str_mv |
2022 |
dc.date.accessioned.none.fl_str_mv |
2024-02-16T22:36:26Z |
dc.date.available.none.fl_str_mv |
2024-02-16T22:36:26Z |
dc.type.spa.fl_str_mv |
Artículo de revista |
dc.type.coar.spa.fl_str_mv |
http://purl.org/coar/resource_type/c_2df8fbb1 |
dc.type.content.spa.fl_str_mv |
Text |
dc.type.driver.spa.fl_str_mv |
info:eu-repo/semantics/article |
dc.type.redcol.spa.fl_str_mv |
http://purl.org/redcol/resource_type/ART |
dc.type.version.spa.fl_str_mv |
info:eu-repo/semantics/publishedVersion |
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http://purl.org/coar/version/c_970fb48d4fbd8a85 |
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dc.identifier.citation.spa.fl_str_mv |
NC Chen, S Kane-Gill, K Suh, EPH21 Real-World Evidence of Adverse Kidney Outcomes for Intravitreal Use of Vascular Endothelial Growth Factor (VEGF) Inhibitors Among Patients with Diabetic Retinopathy, Value in Health, Volume 25, Issue 7, Supplement, 2022, Page S438, ISSN 1098-3015, https://doi.org/10.1016/j.jval.2022.04.774 |
dc.identifier.issn.spa.fl_str_mv |
1098-3015 |
dc.identifier.uri.none.fl_str_mv |
https://hdl.handle.net/11323/10722 |
dc.identifier.doi.none.fl_str_mv |
10.1016/j.jval.2022.04.774 |
dc.identifier.eissn.spa.fl_str_mv |
1524-4733 |
dc.identifier.instname.spa.fl_str_mv |
Corporación Universidad de la Costa |
dc.identifier.reponame.spa.fl_str_mv |
REDICUC – Repositorio CUC |
dc.identifier.repourl.spa.fl_str_mv |
https://repositorio.cuc.edu.co/ |
identifier_str_mv |
NC Chen, S Kane-Gill, K Suh, EPH21 Real-World Evidence of Adverse Kidney Outcomes for Intravitreal Use of Vascular Endothelial Growth Factor (VEGF) Inhibitors Among Patients with Diabetic Retinopathy, Value in Health, Volume 25, Issue 7, Supplement, 2022, Page S438, ISSN 1098-3015, https://doi.org/10.1016/j.jval.2022.04.774 1098-3015 10.1016/j.jval.2022.04.774 1524-4733 Corporación Universidad de la Costa REDICUC – Repositorio CUC |
url |
https://hdl.handle.net/11323/10722 https://repositorio.cuc.edu.co/ |
dc.language.iso.spa.fl_str_mv |
eng |
language |
eng |
dc.relation.ispartofjournal.spa.fl_str_mv |
Value in Health |
dc.relation.citationstartpage.spa.fl_str_mv |
438 |
dc.relation.citationissue.spa.fl_str_mv |
7 |
dc.relation.citationvolume.spa.fl_str_mv |
25 |
dc.rights.eng.fl_str_mv |
© 2022 Published by Elsevier Inc. |
dc.rights.license.spa.fl_str_mv |
Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0) |
dc.rights.uri.spa.fl_str_mv |
https://creativecommons.org/licenses/by-nc-nd/4.0/ |
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info:eu-repo/semantics/embargoedAccess |
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Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0) © 2022 Published by Elsevier Inc. https://creativecommons.org/licenses/by-nc-nd/4.0/ http://purl.org/coar/access_right/c_f1cf |
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embargoedAccess |
dc.format.extent.spa.fl_str_mv |
1 página |
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Elsevier Ltd. |
dc.publisher.place.spa.fl_str_mv |
United Kingdom |
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https://www-sciencedirect-com.ezproxy.cuc.edu.co/science/article/pii/S1098301522009755?via%3Dihub |
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Corporación Universidad de la Costa |
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Atribución-NoComercial-SinDerivadas 4.0 Internacional (CC BY-NC-ND 4.0)© 2022 Published by Elsevier Inc.https://creativecommons.org/licenses/by-nc-nd/4.0/info:eu-repo/semantics/embargoedAccesshttp://purl.org/coar/access_right/c_f1cfChen, NCKane-Gill, SSuh, K2024-02-16T22:36:26Z2024-02-16T22:36:26Z2022NC Chen, S Kane-Gill, K Suh, EPH21 Real-World Evidence of Adverse Kidney Outcomes for Intravitreal Use of Vascular Endothelial Growth Factor (VEGF) Inhibitors Among Patients with Diabetic Retinopathy, Value in Health, Volume 25, Issue 7, Supplement, 2022, Page S438, ISSN 1098-3015, https://doi.org/10.1016/j.jval.2022.04.7741098-3015https://hdl.handle.net/11323/1072210.1016/j.jval.2022.04.7741524-4733Corporación Universidad de la CostaREDICUC – Repositorio CUChttps://repositorio.cuc.edu.co/Objective: Studies of kidney injury following use of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections among patients with diabetic retinopathy have mixed results and are limited by sample size and study design. Our objective was to determine whether intravitreal use of anti-VEGF agents was associated with adverse kidney outcomes compared to treatment with traditional laser photocoagulations. Methods: Adult patients with diabetic retinopathy and use of intravitreal anti-VEGF injections or laser photocoagulation were identified from January 2011, through December 2020 in large nationally representative database of administrative and electronic health record information for commercially insured and Medicare/Medicaid Advantage patients. Outcomes assessed included diagnosis of new chronic kidney disease (CKD), worsening CKD, and a composite endpoint of hospitalization or death using survival analyses. We applied inverse probability treatment weighting using propensity scores and adjusted for demographics, comorbidities, CKD stages at baseline and number of antidiabetic medications. Results: A total of 2,566 patients met the inclusion criteria, with 1,392 patients receiving intravitreal anti-VEGF injections and 1,174 patients receiving laser photocoagulation. Patients in the anti-VEGF group had a 33% higher hazard for newly developed CKD compared to patients in the laser group after adjustment (95% CI: 1.10, 1.60). There was no significant difference in worsening of pre-existing CKD in these two groups (HR=0.93; 95% CI: 0.77, 1.33). Patients treated with intravitreal antiVEGF injections had significantly higher hazards for hospitalizations and mortality compared to those treated with laser photocoagulation (HR=1.17; 95% CI: 1.04, 1.31). Conclusions: While use of anti-VEGF intravitreal injections was not associated with worsening CKD compared to laser photocoagulation, patients without pre-existing CKD had a higher risk of developing newly diagnosed CKD. These results continue to question the effects anti-VEGF injections have on adverse kidney outcomes.1 páginaapplication/pdfengElsevier Ltd.United Kingdomhttps://www-sciencedirect-com.ezproxy.cuc.edu.co/science/article/pii/S1098301522009755?via%3DihubEPH21 Real-world evidence of adverse kidney outcomes for intravitreal use of vascular endothelial growth factor (VEGF) inhibitors among patients with diabetic retinopathyArtículo de revistahttp://purl.org/coar/resource_type/c_2df8fbb1Textinfo:eu-repo/semantics/articlehttp://purl.org/redcol/resource_type/ARTinfo:eu-repo/semantics/publishedVersionhttp://purl.org/coar/version/c_970fb48d4fbd8a85Value in Health438725Diabetic retinopathyVascular Endothelial Growth Factor (VEGF)KidneyPublicationORIGINALEPH21 Real-World Evidence of Adverse Kidney Outcomes for Intravitreal Use of Vascular Endothelial Growth Factor (VEGF) Inhibitors Among Patients with Diabetic Retinopathy.pdfEPH21 Real-World Evidence of Adverse Kidney Outcomes for Intravitreal Use 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Outcomes for Intravitreal Use of Vascular Endothelial Growth Factor (VEGF) Inhibitors Among Patients with Diabetic Retinopathy.pdf.jpgEPH21 Real-World Evidence of Adverse Kidney Outcomes for Intravitreal Use of Vascular Endothelial Growth Factor (VEGF) Inhibitors Among Patients with Diabetic Retinopathy.pdf.jpgGenerated Thumbnailimage/jpeg17253https://repositorio.cuc.edu.co/bitstreams/d1da3053-d6f5-4a94-8285-bcb99a518685/download9b9c87a1f25484ce23ac2f465f5ba5b6MD5411323/10722oai:repositorio.cuc.edu.co:11323/107222024-09-17 11:07:18.002https://creativecommons.org/licenses/by-nc-nd/4.0/© 2022 Published by Elsevier Inc.open.accesshttps://repositorio.cuc.edu.coRepositorio de la Universidad de la Costa 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ada en las Obras Colectivas.

b.	Distribuir copias o fonogramas de las Obras, exhibirlas públicamente, ejecutarlas públicamente y/o ponerlas a disposición pública, incluyéndolas como incorporadas en Obras Colectivas, según corresponda.

c.	Distribuir copias de las Obras Derivadas que se generen, exhibirlas públicamente, ejecutarlas públicamente y/o ponerlas a disposición pública.
Los derechos mencionados anteriormente pueden ser ejercidos en todos los medios y formatos, actualmente conocidos o que se inventen en el futuro. Los derechos antes mencionados incluyen el derecho a realizar dichas modificaciones en la medida que sean técnicamente necesarias para ejercer los derechos en otro medio o formatos, pero de otra manera usted no está autorizado para realizar obras derivadas. Todos los derechos no otorgados expresamente por el Licenciante quedan por este medio reservados, incluyendo pero sin limitarse a aquellos que se mencionan en las secciones 4(d) y 4(e).

4. Restricciones.
La licencia otorgada en la anterior Sección 3 está expresamente sujeta y limitada por las siguientes restricciones:

a.	Usted puede distribuir, exhibir públicamente, ejecutar públicamente, o poner a disposición pública la Obra sólo bajo las condiciones de esta Licencia, y Usted debe incluir una copia de esta licencia o del Identificador Universal de Recursos de la misma con cada copia de la Obra que distribuya, exhiba públicamente, ejecute públicamente o ponga a disposición pública. No es posible ofrecer o imponer ninguna condición sobre la Obra que altere o limite las condiciones de esta Licencia o el ejercicio de los derechos de los destinatarios otorgados en este documento. No es posible sublicenciar la Obra. Usted debe mantener intactos todos los avisos que hagan referencia a esta Licencia y a la cláusula de limitación de garantías. Usted no puede distribuir, exhibir públicamente, ejecutar públicamente, o poner a disposición pública la Obra con alguna medida tecnológica que controle el acceso o la utilización de ella de una forma que sea inconsistente con las condiciones de esta Licencia. Lo anterior se aplica a la Obra incorporada a una Obra Colectiva, pero esto no exige que la Obra Colectiva aparte de la obra misma quede sujeta a las condiciones de esta Licencia. Si Usted crea una Obra Colectiva, previo aviso de cualquier Licenciante debe, en la medida de lo posible, eliminar de la Obra Colectiva cualquier referencia a dicho Licenciante o al Autor Original, según lo solicitado por el Licenciante y conforme lo exige la cláusula 4(c).

b.	Usted no puede ejercer ninguno de los derechos que le han sido otorgados en la Sección 3 precedente de modo que estén principalmente destinados o directamente dirigidos a conseguir un provecho comercial o una compensación monetaria privada. El intercambio de la Obra por otras obras protegidas por derechos de autor, ya sea a través de un sistema para compartir archivos digitales (digital file-sharing) o de cualquier otra manera no será considerado como estar destinado principalmente o dirigido directamente a conseguir un provecho comercial o una compensación monetaria privada, siempre que no se realice un pago mediante una compensación monetaria en relación con el intercambio de obras protegidas por el derecho de autor.

c.	Si usted distribuye, exhibe públicamente, ejecuta públicamente o ejecuta públicamente en forma digital la Obra o cualquier Obra Derivada u Obra Colectiva, Usted debe mantener intacta toda la información de derecho de autor de la Obra y proporcionar, de forma razonable según el medio o manera que Usted esté utilizando: (i) el nombre del Autor Original si está provisto (o seudónimo, si fuere aplicable), y/o (ii) el nombre de la parte o las partes que el Autor Original y/o el Licenciante hubieren designado para la atribución (v.g., un instituto patrocinador, editorial, publicación) en la información de los derechos de autor del Licenciante, términos de servicios o de otras formas razonables; el título de la Obra si está provisto; en la medida de lo razonablemente factible y, si está provisto, el Identificador Uniforme de Recursos (Uniform Resource Identifier) que el Licenciante especifica para ser asociado con la Obra, salvo que tal URI no se refiera a la nota sobre los derechos de autor o a la información sobre el licenciamiento de la Obra; y en el caso de una Obra Derivada, atribuir el crédito identificando el uso de la Obra en la Obra Derivada (v.g., "Traducción Francesa de la Obra del Autor Original," o "Guión Cinematográfico basado en la Obra original del Autor Original"). Tal crédito puede ser implementado de cualquier forma razonable; en el caso, sin embargo, de Obras Derivadas u Obras Colectivas, tal crédito aparecerá, como mínimo, donde aparece el crédito de cualquier otro autor comparable y de una manera, al menos, tan destacada como el crédito de otro autor comparable.

d.	Para evitar toda confusión, el Licenciante aclara que, cuando la obra es una composición musical:

i.	Regalías por interpretación y ejecución bajo licencias generales. El Licenciante se reserva el derecho exclusivo de autorizar la ejecución pública o la ejecución pública digital de la obra y de recolectar, sea individualmente o a través de una sociedad de gestión colectiva de derechos de autor y derechos conexos (por ejemplo, SAYCO), las regalías por la ejecución pública o por la ejecución pública digital de la obra (por ejemplo Webcast) licenciada bajo licencias generales, si la interpretación o ejecución de la obra está primordialmente orientada por o dirigida a la obtención de una ventaja comercial o una compensación monetaria privada.

ii.	Regalías por Fonogramas. El Licenciante se reserva el derecho exclusivo de recolectar, individualmente o a través de una sociedad de gestión colectiva de derechos de autor y derechos conexos (por ejemplo, los consagrados por la SAYCO), una agencia de derechos musicales o algún agente designado, las regalías por cualquier fonograma que Usted cree a partir de la obra (“versión cover”) y distribuya, en los términos del régimen de derechos de autor, si la creación o distribución de esa versión cover está primordialmente destinada o dirigida a obtener una ventaja comercial o una compensación monetaria privada.

e.	Gestión de Derechos de Autor sobre Interpretaciones y Ejecuciones Digitales (WebCasting). Para evitar toda confusión, el Licenciante aclara que, cuando la obra sea un fonograma, el Licenciante se reserva el derecho exclusivo de autorizar la ejecución pública digital de la obra (por ejemplo, webcast) y de recolectar, individualmente o a través de una sociedad de gestión colectiva de derechos de autor y derechos conexos (por ejemplo, ACINPRO), las regalías por la ejecución pública digital de la obra (por ejemplo, webcast), sujeta a las disposiciones aplicables del régimen de Derecho de Autor, si esta ejecución pública digital está primordialmente dirigida a obtener una ventaja comercial o una compensación monetaria privada.

5. Representaciones, Garantías y Limitaciones de Responsabilidad.
A MENOS QUE LAS PARTES LO ACORDARAN DE OTRA FORMA POR ESCRITO, EL LICENCIANTE OFRECE LA OBRA (EN EL ESTADO EN EL QUE SE ENCUENTRA) “TAL CUAL”, SIN BRINDAR GARANTÍAS DE CLASE ALGUNA RESPECTO DE LA OBRA, YA SEA EXPRESA, IMPLÍCITA, LEGAL O CUALQUIERA OTRA, INCLUYENDO, SIN LIMITARSE A ELLAS, GARANTÍAS DE TITULARIDAD, COMERCIABILIDAD, ADAPTABILIDAD O ADECUACIÓN A PROPÓSITO DETERMINADO, AUSENCIA DE INFRACCIÓN, DE AUSENCIA DE DEFECTOS LATENTES O DE OTRO TIPO, O LA PRESENCIA O AUSENCIA DE ERRORES, SEAN O NO DESCUBRIBLES (PUEDAN O NO SER ESTOS DESCUBIERTOS). ALGUNAS JURISDICCIONES NO PERMITEN LA EXCLUSIÓN DE GARANTÍAS IMPLÍCITAS, EN CUYO CASO ESTA EXCLUSIÓN PUEDE NO APLICARSE A USTED.

6. Limitación de responsabilidad.
A MENOS QUE LO EXIJA EXPRESAMENTE LA LEY APLICABLE, EL LICENCIANTE NO SERÁ RESPONSABLE ANTE USTED POR DAÑO ALGUNO, SEA POR RESPONSABILIDAD EXTRACONTRACTUAL, PRECONTRACTUAL O CONTRACTUAL, OBJETIVA O SUBJETIVA, SE TRATE DE DAÑOS MORALES O PATRIMONIALES, DIRECTOS O INDIRECTOS, PREVISTOS O IMPREVISTOS PRODUCIDOS POR EL USO DE ESTA LICENCIA O DE LA OBRA, AUN CUANDO EL LICENCIANTE HAYA SIDO ADVERTIDO DE LA POSIBILIDAD DE DICHOS DAÑOS. ALGUNAS LEYES NO PERMITEN LA EXCLUSIÓN DE CIERTA RESPONSABILIDAD, EN CUYO CASO ESTA EXCLUSIÓN PUEDE NO APLICARSE A USTED.

7. Término.

a.	Esta Licencia y los derechos otorgados en virtud de ella terminarán automáticamente si Usted infringe alguna condición establecida en ella. Sin embargo, los individuos o entidades que han recibido Obras Derivadas o Colectivas de Usted de conformidad con esta Licencia, no verán terminadas sus licencias, siempre que estos individuos o entidades sigan cumpliendo íntegramente las condiciones de estas licencias. Las Secciones 1, 2, 5, 6, 7, y 8 subsistirán a cualquier terminación de esta Licencia.

b.	Sujeta a las condiciones y términos anteriores, la licencia otorgada aquí es perpetua (durante el período de vigencia de los derechos de autor de la obra). No obstante lo anterior, el Licenciante se reserva el derecho a publicar y/o estrenar la Obra bajo condiciones de licencia diferentes o a dejar de distribuirla en los términos de esta Licencia en cualquier momento; en el entendido, sin embargo, que esa elección no servirá para revocar esta licencia o que deba ser otorgada , bajo los términos de esta licencia), y esta licencia continuará en pleno vigor y efecto a menos que sea terminada como se expresa atrás. La Licencia revocada continuará siendo plenamente vigente y efectiva si no se le da término en las condiciones indicadas anteriormente.

8. Varios.

a.	Cada vez que Usted distribuya o ponga a disposición pública la Obra o una Obra Colectiva, el Licenciante ofrecerá al destinatario una licencia en los mismos términos y condiciones que la licencia otorgada a Usted bajo esta Licencia.

b.	Si alguna disposición de esta Licencia resulta invalidada o no exigible, según la legislación vigente, esto no afectará ni la validez ni la aplicabilidad del resto de condiciones de esta Licencia y, sin acción adicional por parte de los sujetos de este acuerdo, aquélla se entenderá reformada lo mínimo necesario para hacer que dicha disposición sea válida y exigible.

c.	Ningún término o disposición de esta Licencia se estimará renunciada y ninguna violación de ella será consentida a menos que esa renuncia o consentimiento sea otorgado por escrito y firmado por la parte que renuncie o consienta.

d.	Esta Licencia refleja el acuerdo pleno entre las partes respecto a la Obra aquí licenciada. No hay arreglos, acuerdos o declaraciones respecto a la Obra que no estén especificados en este documento. El Licenciante no se verá limitado por ninguna disposición adicional que pueda surgir en alguna comunicación emanada de Usted. Esta Licencia no puede ser modificada sin el consentimiento mutuo por escrito del Licenciante y Usted.
 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