The influence of cardiac valvular calcification on all-cause and cardiovascular mortality in maintenance hemodialysis patients

Association of diabetes with cardiovascular calcification and all-cause mortality in end-stage renal disease in the early stages of hemodialysis: a retrospective cohort study

BACKGROUND

The main goal of this study was to examine how diabetes, cardiovascular calcification characteristics and other risk factors affect mortality in end-stage renal disease (ESRD) patients in the early stages of hemodialysis.

METHODS

A total of 285 ESRD patients in the early stages of hemodialysis were enrolled in this research, including 101 patients with diabetes. Survival time was monitored, and general data, biochemical results, cardiac ultrasound calcification of valvular tissue, and thoracic CT calcification of the coronary artery and thoracic aorta were recorded. Subgroup analysis and logistic regression were applied to investigate the association between diabetes and calcification. Cox regression analysis and survival between calcification, diabetes, and all-cause mortality. Additionally, the nomogram model was used to estimate the probability of survival for these individuals, and its performance was evaluated using risk stratification, receiver operating characteristic, decision, and calibration curves.

RESULTS

Cardiovascular calcification was found in 81.2% of diabetic patients (82/101) and 33.7% of nondiabetic patients (62/184). Diabetic patients had lower phosphorus, calcium, calcium-phosphorus product, plasma PTH levels and lower albumin levels (p < 0.001). People with diabetes were more likely to have calcification than people without diabetes (OR 5.66, 95% CI 1.96-16.36; p < 0.001). The overall mortality rate was 14.7% (42/285). The risk of death was notably greater in patients with both diabetes and calcification (29.27%, 24/82). Diabetes and calcification, along with other factors, collectively predict the risk of death in these patients. The nomogram model demonstrated excellent discriminatory power (area under the curve (AUC) = 0.975 at 5 years), outstanding calibration at low to high-risk levels and provided the greatest net benefit across a wide range of clinical decision thresholds.

CONCLUSIONS

In patients with ESRD during the early period of haemodialysis, diabetes significantly increases the risk of cardiovascular calcification, particularly multisite calcification, which is correlated with a higher mortality rate. The risk scores and nomograms developed in this study can assist clinicians in predicting the risk of death and providing individualised treatment plans to lower mortality rates in the early stages of hemodialysis.

Association between serum beclin 1 level and cardiac valvular calcification in hemodialysis patients

BACKGROUND

Cardiovascular calcification is a pervasive issue throughout chronic kidney disease (CKD) progression. Autophagy, a fundamental cellular process, exerts significant influence on various cardiac pathologies, including arrhythmias, atherosclerosis, heart failure, and notably, valvular, and vascular calcifications. Beclin-1, a crucial eukaryotic protein, plays a major regulatory role in autophagy as part of the phosphatidylinositol-3-kinase (PI3K) complex. Recent evidence suggests a protective role for Beclin-1-mediated autophagy in CKD vascular calcification, raising its potential as a novel therapeutic target in this context.

WE AIMED TO

Investigate the association between serum Beclin 1 levels and the presence of cardiovascular valvular calcification in hemodialysis patients.

RESULTS

This study evaluated a cohort of 102 hemodialysis patients, evenly divided into two groups based on echocardiographic findings. All participants underwent serum Beclin 1 measurement and transthoracic echocardiography. Patients with acute kidney injury, active malignancy, or diabetes were excluded. Our study revealed significant differences between the two groups in terms of: Serum Beclin 1 levels, all parameters of lipid profile, prevalence of ischemic heart disease, serum albumin levels and Total calcium. Echocardiography in Group 1 showed that most cases (60.78%) exhibited mild aortic valve calcification. Additionally, significant relationships were observed between Beclin 1 and: ischemic heart disease (p=0.011) Aortic valve calcification on echocardiography (p < 0.001) Interestingly, lower Beclin 1 levels were associated with more severe valve calcification. A Beclin 1 cutoff value of ≤ 35.5 ng/ml demonstrated the highest sensitivity (98%) and specificity (92%).

CONCLUSION

Our findings suggest that the serum Beclin 1 level could be incorporated into a predictive model for cardiac valvular calcification in hemodialysis patients.

The number of valvular insufficiency is a strong predictor of cardiovascular and all-cause mortality in hemodialysis patients

OBJECTIVES

To investigate the relationship between the number of valvular insufficiency (VI) and emergency hospitalization or mortality in maintenance hemodialysis (HD) patients.

METHODS

The maintenance HD patients with cardiac ultrasonography were included. According to the number of VI ≥ 2 or not, the patients were divided into two groups. The difference of emergency hospitalized for acute heart failure, arrhythmia, acute coronary syndrome (ACS) or stroke, cardiovascular mortality, and all-cause mortality between the two groups were compared.

RESULTS

Among 217 maintenance HD patients, 81.57% had VI. 121 (55.76%) patients had two or more VI, and 96 (44.24%) with one VI or not. The study subjects were followed up for a median of 47 (3-107) months. At the end of the follow up, 95 patients died (43.78%), of whom 47 (21.66%) patients died because of cardiovascular disease. Age (HR 1.033, 95% CI 1.007-1.061, P = 0.013), number of VI ≥ 2 (HR 2.035, 95% CI 1.083-3.821, P = 0.027) and albumin (HR 0.935, 95% CI 0.881-0.992, P = 0.027) were independent risk factors for cardiovascular mortality. The three parameters were also independent risk factors for all-cause mortality. The patients with number of VI ≥ 2 were more likely to be emergency hospitalized for acute heart failure (56 [46.28%] vs 11 [11.46%], P = 0.001). On the contrary, the number of VI was not associated with emergency hospitalized for arrhythmia, ACS or stroke. Survival analysis results showed that probability of survival was statistically different in the two groups (P < 0.05), no matter based on cardiovascular mortality or all-cause mortality. Based on age, number of VI ≥ 2 and albumin, nomogram models for 5-year cardiovascular and all-cause mortality were built.

CONCLUSIONS

In maintenance HD patients, the prevalence of VI is prominently high. The number of VI ≥ 2 is associated with emergency hospitalized for acute heart failure, cardiovascular and all-cause mortality. Combining age, number of VI ≥ 2, and albumin can predict cardiovascular and all-cause mortality.

Influencing factors of cardiac valve calcification (CVC) in patients with chronic kidney disease and the impact of CVC on long-term prognosis: a single-center retrospective study

Objective

To investigate the effect of cardiac valve calcification (CVC) on the prognosis of patients with chronic kidney disease (CKD).

Methods

A total of 343 CKD patients were retrospectively analyzed, and divided into two groups according to the presence or absence of cardiac valve calcification. All patients were followed until death, loss to follow-up, or the end point of the study (December 2021).

Results

The incidence of CVC among the 343 CKD patients was 29.7%, including 21 cases of mitral valve calcification, 63 cases of aortic valve calcification, and 18 cases of mitral valve combined with aortic valve calcification. The incidence of CVC in CKD stages 1-2 was 0.3%, 5.2% in CKD stages 3-4, and 24.2% in CKD stage 5 (P < 0.05). Advanced age, higher serum albumin, higher cystatin C and lower uric acid levels were all associated with a higher risk of CVC. After six years of follow-up, 77 patients (22.4%) died. The causes of death were cardiovascular and cerebrovascular diseases in 36 cases (46.7%), infection in 29 cases (37.7%), gastrointestinal bleeding in nine cases (11.7%), and "other" in the remaining three cases (3.9%). A Kaplan Meier survival analysis showed that the overall survival rate of patients with CVC was lower than that of patients without CVC.

Conclusion

The incidence of CVC, mainly aortic calcification, is high in patients with CKD. Advanced age, higher serum albumin and higher cystatin C levels were associated with a higher risk of CVC. Hyperuricemia was associated with a lower risk of CVC. The overall survival rate of patients with CVC was lower than that of patients without CVC.

Associated factors of cardiac valve calcification and its prognostic effects among patients with chronic kidney disease: a systematic review and meta-analysis

Background

Cardiac valve calcification (CVC) is highly prevalent and a risk factor for adverse outcomes in patients with chronic kidney disease (CKD). This meta-analysis aimed to investigate the risk factors for CVC and association between CVC and mortality in CKD patients.

Method

Three electronic databases including PubMed, Embase, and Web of Science were searched for relevant studies up to November 2022. Hazard ratios (HR), odds ratios (OR), and 95% confidence intervals (CI) were pooled using random-effect meta-analyses.

Results

22 studies were included in the meta-analysis. Pooled analyses showed that CKD patients with CVC were relatively older, had a higher body mass index, left atrial dimension, C-reaction protein level, and a declined ejection fraction. Calcium and phosphate metabolism dysfunction, diabetes, coronary heart disease, and duration of dialysis were all predictors for CVC in CKD patients. The presence of CVC (both aortic valve and mitral valve) increased the risk of all-cause and cardiovascular mortality in CKD patients. However, the prognostic value of CVC for mortality was not significant anymore in patients with peritoneal dialysis.

Conclusion

CKD patients with CVC had a greater risk of all-cause and cardiovascular mortality. Multiple associated factors for development of CVC in CKD patients should be taken into consideration by healthcare professionals to improve prognosis.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42022364970].

Association of aortic arch and aortic valve calcifications with cardiovascular risk in patients on maintenance hemodialysis

Introduction

This study aimed to investigate the association of aortic arch calcification (AoAC) and aortic valve calcification (AVC) with major adverse cardiovascular events (MACE) and cardiovascular and all-cause mortality in patients on maintenance hemodialysis (MHD).

Methods

This study enrolled 297 adult patients with end-stage kidney disease who were on MHD. They were divided into those with an AoAC score <2 without AVC (n = 70, 23.6%), those with an AoAC score <2 with AVC (n = 96, 32.3%), and those with an AoAC score ≥2 regardless of AVC status (n = 131, 44.1%). We analyzed the risks of MACE, cardiovascular and overall mortality among the three groups using Cox proportional hazard analyses. Survival probabilities were estimated using the log-rank test via the Kaplan-Meier method.

Results

Kaplan-Meier analysis revealed that the MACE-free rate and the survival rates of cardiovascular and overall mortality were significantly higher in adult chronic hemodialysis patients with AoAC score <2 without AVC, followed by those with AoAC score <2 with AVC, and then those with AoAC score ≥2 (log-rank test; all p < 0.01). The grade of AoAC is a significant risk factor for MACE, cardiovascular mortality, and overall mortality after adjusting for age and gender Relative to AoAC score <2 without AVC, adult chronic hemodialysis patients with AoAC score ≥2 remained an independently significantly risk factor of MACE (adjusted hazard ratio, 2.17; 95% confidence interval 1.11-4.20; p = 0.023) after adjusting for age, sex, and all significant variables in baseline characteristics.

Conclusion

AoAC grade was positively correlated with a higher risk of MACE and cardiovascular and overall mortality. Furthermore, the presence of AVC modified the adverse cardiovascular risk associated with AoAC in patients on MHD.

Cardiac valve calcification as a predictor of cardiovascular outcomes in peritoneal dialysis patients: an inverse probability of treatment weighting analysis

BACKGROUND

Cardiovascular events (CVE) are the leading cause of death in peritoneal dialysis (PD) patients. The predictive value of cardiac valve calcification (CVC) for CVE in dialysis patients remains controversial. In particular, such studies are limited in PD patients. We aimed to examine the predictive role of CVC for CVE and cardiovascular mortality in PD patients.

METHODS

A retrospective analysis was performed on patients who initiated PD in our hospital. According to the result of echocardiography, patients were divided into CVC group and non-CVC group. The differences in baseline demographic characteristics, biochemical variables, comorbidities, and clinical outcomes between the two groups were compared. Kaplan-Meier method was used to obtain survival curves. The Cox regression model was used to evaluate the influence of CVC for cardiovascular outcomes. The inverse probability of treatment weighting (IPTW) was used to eliminate influence of the confounders in the groups.

RESULTS

458 peritoneal dialysis patients were enrolled in this study. 77 patients were in CVC group and 381 patients in non-CVC group. The average follow-up time was (32 ± 21) months. At baseline, the absolute standardized difference (ASD) of age, BMI, history of CVE, diabetes, LVEF, LVMI, albumin, calcium, phosphorus, triglycerides, hsCRP, urine volume, Kt/V, statins and vitamin D intake rate were greater than 0.1 between the two groups. All of ASD dropped to less than 0.1 after IPTW, which meant that the balance had been reached between the two groups. Multivariable logistic analysis showed that advanced age, diabetes, and hyperphosphatemia were associated with CVC. The Kaplan-Meier survival curve showed the cumulative CVE-free survival rate and cardiovascular survival rate of CVC group were significantly lower than that of non-CVC group before and after IPTW (log-rank P < 0.05). After IPTW was used to eliminate the effect of confounders, multivariate Cox regression analysis still showed CVC was an independent risk factor for CVE (HR = 2.383, 95% CI 1.331~4.264, P = 0.003) and cardiovascular mortality (HR = 2.347, 95% CI 1.211~4.548, P = 0.012) in PD patients.

CONCLUSION

The prevalence of CVC is high in peritoneal dialysis patients. CVC is an independent risk factor for CVE and cardiovascular mortality in peritoneal dialysis patients.

The interaction analysis between advanced age and longer dialysis vintage on the survival of patients receiving maintenance hemodialysis

Objective

To compare the all-cause mortality of aged and younger patients undergoing maintenance hemodialysis (MHD) over the long or short term, and to identify independent risk factors.

Methods

We performed a retrospective cohort study using the medical records of 181 patients undergoing MHD. We compared the clinical characteristics and laboratory data of survivors and participants who died, according to their age and the duration of MHD. Binary stepwise logistic regression was used to identify independent risk factors for all-cause mortality.

Results

Cardiovascular and cerebrovascular diseases were the principal causes of mortality. The number of aged participants with hypertensive nephropathy as their primary kidney disease was significantly higher than the number of younger participants. The proportion with chronic glomerulonephritis was significantly higher for participants undergoing long-term MHD. Logistic regression analysis revealed that low body mass index, single-pool Kt/V, serum albumin, platelet count, and total iron-binding capacity; and high intact parathyroid hormone and N terminal pro B type natriuretic peptide were independent risk factors for all-cause mortality.

Conclusions

Aged patients are more susceptible to hypertensive nephropathy than younger patients. In addition, the survival of patients with chronic glomerulonephritis undergoing MHD is superior to that of those with hypertensive or diabetic nephropathy.

Prognosis and risk factors for cardiac valve calcification in Chinese end-stage kidney disease patients on combination therapy with hemodialysis and hemodiafiltration

BACKGROUND

Cardiac valve calcification (CVC) is an important risk factor for cardiovascular complications. However, limited data are available concerning the prevalence, clinical features and risk factors for CVC in end-stage kidney disease (ESKD) patients. In this study, we aimed to assess these parameters in Chinese ESKD patients receiving combination therapy with hemodialysis and hemodiafiltration.

METHODS

We conducted a cross-sectional study on 293 ESKD patients undergoing combination therapy of hemodialysis and hemodiafiltration at the First Affiliated Hospital of Chongqing Medical University from October 2014 to December 2015. CVC was evaluated via echocardiography.

RESULTS

ESKD patients with CVC had a higher prevalence of diabetes mellitus, aortic and/or coronary artery calcification, arrhythmia, heart failure and coronary heart disease; increased systolic, diastolic and pulse pressure; longer duration of hemodialysis and hypertension; reduced hemoglobin, albumin and high-density lipoprotein cholesterol levels; and increased serum calcium and calcium-phosphorus product levels compared with those without CVC. Logistic regression analysis showed that increased dialysis duration (p = 0.006, OR = 2.25), serum calcium levels (p = 0.046, OR = 2.04) and pulse pressure (p < 0.001, OR = 3.22), the presence of diabetes (p = 0.037, OR = 1.81) and decreased serum albumin levels (p = 0.047, OR = 0.54) were risk factors for CVC. The correlation analysis indicated a significantly increased CVCs prevalence with an increase prevalence of heart failure, aortic and coronary artery calcification.

CONCLUSIONS

CVC represents a common complication and a danger signal for cardiovascular events in ESKD patients undergoing combination therapy of hemodialysis and hemodiafiltration. The presence of diabetes, increased pulse pressure, long dialysis duration, hypoalbuminemia and high serum calcium levels were independent risk factors for CVC.

Echocardiographic left ventricular hypertrophy and geometry in Chinese chronic hemodialysis patients: the prevalence and determinants

Background

To investigate the prevalence of left ventricular hypertrophy (LVH) and explore left ventricular geometry in maintenance hemodialysis (MHD) patients, and to explore the risk factors of LVH which is an important predictor of cardiovascular events.

Methods

The subjects were patients who are on MHD for more than 3 months in Peking University People's Hospital from March 2015 to February 2017. Demographic and clinical data were retrospectively collected. Left ventricular mass was measured by echocardiography. LVH is defined by Left ventricular mass index (LVMI) > 115 g/m² for men and > 95 g/m² in women. LVMI and relative wall thickness were used to determine left ventricular geometry. Logistic regression was used to analyze the risk factors of LVH.

Results

Altogether, 131 patients including 77 males were enrolled. The median age was 60 (47, 69) years, with a median dialysis vintage of 48 (18, 104) months. There were 80 patients with LVH, the prevalence rate was 61.1%, and 66.3% of them were moderate to severe LVH. We found that (1) most of the patients were concentric hypertrophy; (2) one-third of the patients were concentric remodeling; (3) only 4 cases with normal geometry. The pre-dialysis serum sodium level and time average pre-dialysis systolic blood pressure (SBP) were independent risk factors of LVH.

Conclusion

LVH is prevalent in MHD patients. Concentric hypertrophy and concentric remodeling are the most common geometric patterns. Attention should be paid to long-term pre-dialysis SBP management and pre-dialysis sodium control as they might be potentially modifiable risk factors for LVH.

Cardiac valve calcification is associated with mortality in hemodialysis patients: a retrospective cohort study

Background

Cardiac valve calcification (CVC) is common in end-stage renal disease (ESRD). We investigated the effect of CVC on all-cause and cardiovascular (CV) mortality in maintenance hemodialysis (MHD) patients.

Methods

A retrospective cohort study was conducted on 434 hemodialysis patients who underwent echocardiography for qualitative assessment of valve calcification with complete follow-up data from January 1, 2014, to April 30, 2021. The baseline data between the CVC and non-CVC groups were compared. The Kaplan–Meier method was used to analyse all-cause and cardiovascular mortality. The association of CVC with all-cause and cardiovascular mortality was evaluated using multivariate Cox regression analysis.

Results

Overall, 27.2% of patients had mitral valve calcification (MVC), and 31.8% had aortic valve calcification (AVC) on echocardiography. Patients with CVC showed significantly higher all-cause (log-rank P < 0.001) and cardiovascular (log-rank P < 0.001) mortality rates than patients without CVC. In multivariate regression analyses, MVC (HR: 1.517, P = 0.010) and AVC (HR: 1.433, P = 0.028) were significant factors associated with all-cause mortality. MVC (HR: 2.340, P < 0.001) and AVC (HR: 2.410, P < 0.001) were also significant factors associated with cardiovascular mortality.

Conclusions

MVC and AVC increased the risk of all-cause and cardiovascular mortality in MHD patients. Regular follow-up with echocardiography could be a useful method for risk stratification in MHD patients.

All-cause and cardiovascular mortality in patients undergoing hemodialysis with aortic sclerosis and mild-to-moderate aortic stenosis: A cohort study

BACKGROUND AND AIMS

Mild-to-moderate aortic stenosis (AS) and aortic sclerosis, a precursor of AS, are associated with mortality in the general population; however, their association in patients undergoing hemodialysis with higher morbidity of AS is unknown. Thus, we investigated the mortality of aortic sclerosis and mild-to-moderate AS in patients undergoing hemodialysis.

METHODS

This was a retrospective multicenter cohort study of consecutive patients undergoing hemodialysis at nine dialysis facilities who underwent screening echocardiography between January 2008 and December 2019. We investigated the mortality of patients with aortic sclerosis or mild-to-moderate AS using multivariable Cox proportional hazards regression.

RESULTS

Among 1,878 patients undergoing hemodialysis, those with normal aortic valves, aortic sclerosis, mild AS, moderate AS, severe AS, and prosthetic aortic valves were 844 (45%), 793 (42%), 161 (8.6%), 38 (2.0%), 11 (0.6%), and 31 (1.7%), respectively. After excluding patients with severe AS and prosthetic aortic valves, we performed comparative analysis on 1,836 patients (mean age, 67 years; 66% male). In a median follow-up of 3.6 years, crude death rates (per 100 person-years) were 5.2, 10.6, and 13.0 in patients with normal aortic valves, aortic sclerosis, and mild-to-moderate AS, respectively. Compared with normal aortic valves, both aortic sclerosis and mild-to-moderate AS were associated with all-cause and cardiovascular death: adjusted hazard ratios (95% confidence intervals) were 1.36 (1.13-1.65) and 1.36 (1.02-1.80) for all-cause death; and 1.52 (1.06-2.17) and 1.74 (1.04-2.92) for cardiovascular death, respectively.

CONCLUSIONS

Aortic sclerosis and mild-to-moderate AS were independent risk factors for all-cause and cardiovascular death in patients undergoing hemodialysis.

The Association between Changes in Low Parathyroid Hormone Levels and Cardiac Function Decline in Maintenance Hemodialysis Patients: A Prospective Observational Study

OBJECTIVES

The aim of this study was to investigate a possible association between changes in low parathyroid hormone (PTH) levels and cardiac function decline in maintenance hemodialysis (MHD) patients.

METHODS

A total of 150 MHD patients were included and followed for 24 months. The enrolled patients were divided into 3 groups based on their PTH status at baseline and 24 months. Factors potentially involved in changes in the PTH level and cardiac function were compared using multivariate logistic regression analysis.

RESULTS

At 24 months, the presence of low PTH levels increased by 26.7%. The main independent factors for low PTH levels were a low BMI, hemoglobin, and serum albumin and high serum calcium (p < 0.05). A persistently low PTH level at 24 months was associated with a decrease in the left ventricular ejection fraction (LVEF) and increase in valvular calcification (p < 0.05). Additionally, a decrease in PTH levels from normal or high to low values was associated with a decrease in LVEF and cardiac output (CO) and an increase in valvular calcification (p < 0.05). Furthermore, compared with those of the persistently low PTH level group, LVEF values were lower at 24 months in the group with a decrease from high/normal to low PTH level (p < 0.05).

CONCLUSION

Persistently low PTH levels and changes in the PTH level from high/normal to low were associated with cardiac function decline in MHD patients. Moreover, a PTH level change from high/normal to low showed a stronger correlation with cardiac function decline.