Association of non-invasive measures of subclinical atherosclerosis and arterial stiffness with mortality and major cardiovascular events in chronic kidney disease: systematic review and meta-analysis of cohort studies

Extracellular matrix in vascular homeostasis and disease

The extracellular matrix is an essential component and constitutes a dynamic microenvironment of the vessel wall with an indispensable role in vascular homeostasis and disease. From early development through to ageing, the vascular extracellular matrix undergoes various biochemical and biomechanical alterations in response to diverse environmental cues and exerts precise regulatory control over vessel remodelling. Advances in novel technologies that enable the comprehensive evaluation of extracellular matrix components and cell-matrix interactions have led to the emergence of therapeutic strategies that specifically target this fine-tuned network. In this Review, we explore various aspects of extracellular matrix biology in vascular development, disorders and ageing, emphasizing the effect of the extracellular matrix on disease initiation and progression. Additionally, we provide an overview of the potential therapeutic implications of targeting the extracellular matrix microenvironment in vascular diseases.

Benefits of aldosterone receptor antagonism in chronic kidney disease: the BARACK-D RCT

Background

Chronic kidney disease affects around 10% of the global population and is associated with significant risk of progression to end-stage renal disease and vascular events. Aldosterone receptor antagonists such as spironolactone have shown prognostic benefits in patients with heart failure, but effects on patients with chronic kidney disease are uncertain.

Objectives

To determine the effect of low-dose spironolactone on mortality and cardiovascular outcomes in people with chronic kidney disease stage 3b.

Design

Prospective randomised open blinded end-point trial.

Settings

Three hundred and twenty-nine general practitioner practices throughout the United Kingdom.

Participants

Patients meeting the criteria for chronic kidney disease stage 3b (estimated glomerular filtration rate 30-44 ml/minute/1.73 m2) according to National Institute for Health and Care Excellence guidelines were recruited. Due to the higher than anticipated measurement error/fluctuations, the eligible range was extended to 30-50 ml/minute/1.73 m2 following the initial recruitment period.

Intervention

Participants were randomised 1 : 1 to receive either spironolactone 25 mg once daily in addition to standard care, or standard care only.

Outcome measures

Primary outcome was the first occurring of all-cause mortality, first hospitalisation for heart disease (coronary heart disease, arrhythmia, atrial fibrillation, sudden death, failed sudden death), stroke, heart failure, transient ischaemic attack or peripheral arterial disease, or first occurrence of any condition not listed at baseline. Secondary outcome measures included changes in blood pressure, renal function, B-type natriuretic peptide, incidence of hyperkalaemia and treatment costs and benefits.

Results

One thousand four hundred and thirty-four participants were randomised of the 3022 planned. We found no evidence of differences between the intervention and control groups in terms of effectiveness with the primary combined vascular end points, nor with the secondary clinical outcomes, including progression in renal decline. These results were similar for the total treatment periods or a 3-year follow-up period as originally planned. More adverse events were experienced and more participants discontinued treatment in the intervention group. Two-thirds of participants randomised to spironolactone stopped treatment within six months because they met pre-specified safety stop criteria. The addition of low-dose spironolactone was estimated to have a cost per quality-adjusted life-year gained value above the National Institute for Health and Care Excellence's threshold of £30,000.

Limitations

Main limitations were difficulties in recruiting eligible participants resulting in an underpowered trial with poor ethnic diversity taking twice as long as planned to complete. We have explored the data in secondary analyses that indicate that, despite these difficulties, the findings were reliable.

Conclusions

The benefits of aldosterone receptor antagonism in chronic kidney disease trial found no evidence to support adding low-dose spironolactone (25 mg daily) in patients with chronic kidney disease stage 3b: there were no changes to cardiovascular events during the trial follow-up, either for the combined primary or individual components. There was also no evidence of benefit observed in rates of renal function decline over the trial, but much higher initial creatinine rise and estimated glomerular filtration rate decline, and to a higher percentage rate, in the intervention arm in the first few weeks of spironolactone treatment, which resulted in a high proportion of participants discontinuing spironolactone treatment at an early stage. These higher rates of negative renal change reduced in scale over the study but did not equalise between arms. The addition of 25 mg of spironolactone therefore provided no reno- or cardio-protection and was associated with an increase in adverse events.

Future work

These findings might not be applicable to different mineralocorticoid receptor antagonists.

Study registration

Current Controlled Trials ISRCTN44522369.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/01/52) and is published in full in Health Technology Assessment; Vol. 29, No. 5. See the NIHR Funding and Awards website for further award information.

Gender Difference in Orthostatic Vascular Stiffness Increase in Young Subjects

Background/Objectives: Early detection of increased vascular stiffness in young populations may facilitate the development of more effective strategies for the primary prevention of arterial hypertension and other age-related cardiovascular diseases. To examine gender differences in orthostatic increases in vascular stiffness during the head-up tilt test (HUTT), standardized by hydrostatic column height. Materials and Methods: A total of 133 healthy adults aged 18-20 years (93 females and 40 males) were evaluated. Blood pressure and pulse wave velocity at the brachial-ankle artery site (baPWV) were measured using an ABI system 100 PWV multichannel sphygmomanometer. Orthostatic changes in arterial stiffness were assessed during a head-up tilt test (HUTT) using the Luanda protocol, which standardizes hydrostatic column height. The functional reserve coefficient (FRC) of orthostatic circulatory regulation was introduced as a measure of adaptive capacity: FRC = ΔbaPWV/baPWVb. This coefficient accounts for both structural (baPWVb) and functional (ΔbaPWV = baPWVt - baPWVb) components influencing cardiovascular system adaptation, which exhibit multidirectional changes with age. Results: Baseline baPWV (baPWVb) values in the horizontal position showed no significant differences between genders and were within normal age ranges. However, baPWV values in the upright HUTT position (baPWVt) were significantly higher in men (p = 0.0007). Dynamic biomarkers of vascular reserve, including ΔbaPWV and FRC, were also significantly elevated in men (p = 0.0009 and p = 0.0064, respectively). Conclusions: While baseline baPWVb values were comparable between genders, dynamic biomarkers of vascular reserve, such as ΔbaPWV and FRC, were significantly higher in men. Prospective studies are needed to establish optimal reference values for these dynamic biomarkers, enabling the assessment of individual trends in vascular aging and evaluating the effects of treatment, lifestyle modifications, and other preventive measures on vascular health.

Changes in the cardiovascular risk profile in children approaching kidney replacement therapy

Background

Despite significant cardiovascular (CV) morbidity in children on dialysis and after kidney transplantation, data on the evolution of CV damage in children with chronic kidney disease (CKD) approaching kidney replacement therapy (KRT) is unknown.

Methods

The burden, progression, and predictors of CV damage before KRT onset were explored in two prospective multicenter cohorts from Europe and Canada: Cardiovascular Comorbidity in Children with CKD (4C) and Haemodiafiltration, Heart and Height (3H) studies, conducted from 2009-19 and 2013-16, respectively. CV damage and risk factors were evaluated (i) cross sectionally at KRT-start (n = 248), and (ii) longitudinally over the 2-years preceding KRT start (n = 157; 331 patient-visits). Longitudinal analyses with mixed-effects models estimated associations of modifiable CV risk factors with change in carotid intima-media thickness (cIMT) standard deviation score (SDS), pulse wave velocity (PWV-SDS), left ventricular (LV) mass and systolic dysfunction.

Findings

248 patients, age 14.3 (12.2, 16.2) years were evaluated at median 35 (28-114) days before KRT start. Elevated cIMT-SDS and PWV-SDS were present in 43% and 25%, and LV hypertrophy and systolic dysfunction in 49% and 33%. Aortic stiffness and LV hypertrophy significantly increased, especially in the year before KRT start (adjusted odds ratio, OR 0.33, P = 0.002 and OR 0.54, P = 0.01, respectively). 79% of children had >3 modifiable CV risk factors at KRT onset. Diastolic BP and BMI were strongly associated with a linear increase in all CV measures. After controlling for CV risk factors, the time to KRT onset no longer predicted the burden of CV damage.

Interpretation

This comprehensive CV evaluation shows the progressive accrual of modifiable risk factors and a high burden of CV damage in the years preceding KRT onset. CV damage in the pre-KRT period is preventable.

Funding

Supported by EU4Health Programme (101085068) and Kidney Research UK (RP39/2013).

Effect of regulated vitamin D increase on vascular markers in patients with chronic kidney disease: A systematic review and meta-analysis of randomized controlled trials

AIM

The effect of increased vitamin D levels on vascular function in patients with chronic kidney disease (CKD) is controversial. This meta-analysis aimed to assess the effect of regulated vitamin D increase on vascular markers in patients with CKD.

DATA SYNTHESIS

We searched PubMed, Web of Science, Embase and ClinicalTrials.gov from database inception up until July 21, 2023. We included randomized controlled trials assessing the effects of using vitamin D and its analogues on vascular function in patients with CKD. Fixed-effects and random-effects model analyses were performed using weighted mean difference effects for each trial by heterogeneity (I2) assessment. Primary outcomes encompassed blood flow-mediated dilation (FMD)、pulse wave velocity (PWV) and augmentation index (AIx).

FINDINGS

From 1964 records we selected 12 trials, 5 (n = 331) on FMD, 8 (n = 626) on PWV and 4 (n = 393) on AIx. Vitamin D and VDRA supplementation failed to significantly improve FMD (WMD 1.68%; 95% CI -0.18 to 3.53; P = 0.08; I2 = 88%)、PWV (WMD -0.41 m/s; 95%CI -0.95 to 0.13; P = 0.14; I2 = 57%)and AIx (WMD -0.53%; 95%CI -1.69 to 0.63; P = 0.37; I2 = 0%). Subgroup analysis revealed that 2 μg paricalcitol significantly improved FMD (WMD 2.09%; 95%CI 1.28 to 2.90; P < 0.00001); I2 = 0%), as did cholecalciferol (WMD 5.49%; 95% CI 4.35 to 6.63; P < 0.00001).

CONCLUSION

Supplementation vitamin D and VDRA are associated with improved vascular function as measured by FMD, but not arterial stiffness as measured by PWV and AIx, tentatively suggesting that regulating the increase of vitamin D could not potentially reduce the incidence of cardiovascular disease.

Wall Properties of Elastic and Muscular Arteries in Children and Adolescents at Increased Cardiovascular Risk

BACKGROUND

Pulse wave velocity (PWV) assessment represents a simple method to estimate arterial distensibility. At present, carotid-femoral PWV (cf-PWV) is considered the gold standard method in the non-invasive evaluation of the elastic properties of the aorta. On the other hand, the mechanical properties of muscular arteries can be evaluated on the axillo-brachial-radia axis by estimating the carotid-radial PWV (cr-PWV). While a number of studies have addressed these issues in adults, limited information is available on the respective features of cf-PWV and cr-PWV and on their modulating factors in children and adolescents at increased cardiovascular risk.

METHODS

The mechanical properties of the predominantly elastic (aorta) and muscular (axillo-brachial-radial axis) arteries were evaluated in a pediatric population characterized by either elevated blood pressure (BP) or excess body weight, and the main factors affecting cf-PWV and cr-PWV values in these individuals were investigated.

RESULTS

443 children and adolescents (median age 11.5 years, 43.3% females) were enrolled; 25% had BP values >90th percentile and 81% were excess weight. The cf-PWV values were significantly lower than the cr-PWV values: median (Q1-Q3) = 4.8 m/s (4.3-5.5) and 5.8 m/s (5.0-6.5), respectively (p < 0.001). The pubertal development (p < 0.03), systolic BP and diastolic BP z-scores (p = 0.002), heart rate (p < 0.001), and waist-to-height ratio (p < 0.005) were significantly associated with cf-PWV values. No significant association was found between BMI z-score and cf-PWV. Predictors of high cf-PWV (>95th percentile) were the heart rate (OR 1.07, 95%CI 1.04-1.10, p < 0.001) and waist-to-height ratio (OR 1.06, 95%CI 1.0-1.13, p = 0.04). The variables significantly related with cr-PWV values were diastolic BP z-score (p = 0.001), heart rate (p < 0.01), and HOMA index (p < 0.02). No significant association was found between the cr-PWV and BMI z-score or waist-to-height ratio.

CONCLUSIONS

Systolic and diastolic BP values and central obesity are associated with aortic stiffness in a population of children and adolescents at increased cardiovascular risk. In contrast, diastolic BP, heart rate, and levels of insulin resistance appear to be related to distensibility of the upper limb vascular district.

Can we reverse arterial stiffness by intervening on CKD-MBD biomarkers?

The increased cardiovascular risk of chronic kidney disease may in part be the consequence of arterial stiffness, a typical feature of kidney failure. Deranged homeostasis of minerals and hormones involved (CKD-MBD), are also strongly associated with this increased risk. It is well established that CKD-MBD is a main driver of vascular calcification, which in turn worsens arterial stiffness. However, there are other contributors to arterial stiffness in CKD than calcification. An overlooked possibility is that CKD-MBD may have detrimental effects on this potentially better modifiable component of arterial stiffness. In this review, the individual contributions of short-term changes in calcium, phosphate, PTH, vitamin D, magnesium, and FGF23 to arterial stiffness, in most studies assessed as pulse wave velocity, is summarized. Indeed, there is evidence from both observational studies and interventional trials that higher calcium concentrations can worsen arterial stiffness. This, however, has not been shown for phosphate, and it seems unlikely that, apart from being a contributor to vascular calcification and having effects on the microcirculation, phosphate has no acute effect on large artery stiffness. Several interventional studies, both by infusing PTH and by abrupt lowering PTH by calcimimetics or surgery, virtually ruled out direct effects on large artery stiffness. A well-designed trial using both active and nutritional vitamin D as intervention found a beneficial effect for the latter. Unfortunately, the study had a baseline imbalance and other studies did not support its finding. Both magnesium and FGF23 do not seem do modify central arterial stiffness.

Current and Emerging Markers and Tools Used in the Diagnosis and Management of Chronic Kidney Disease-Mineral and Bone Disorder in Non-Dialysis Adult Patients

Chronic kidney disease (CKD) is a significant public health concern associated with significant morbidity and has become one of the foremost global causes of death in recent years. A frequent comorbidity of CKD is secondary hyperparathyroidism (SHPT), exemplified by high serum parathyroid hormone (PTH) levels. The mineral metabolism disturbances resulting from CKD and progression to SHPT are currently considered part of the definition of chronic kidney disease-mineral and bone disorder (CKD-MBD). However, CKD-MBD does not only include abnormalities in laboratory-measured parameters; it is a complex condition characterized by dysregulation of bone turnover, mineralization, growth and strength, accompanied by vascular or another soft-tissue calcification. Together, this increases the risk of bone fractures, cardiovascular disease, and overall mortality in CKD-MBD patients. Monitoring serum markers is essential in diagnosing SHPT and CKD-MBD, and there are several recognized indicators for prognosis, optimal clinical management and treatment response in late-stage kidney disease patients receiving dialysis. However, far fewer markers have been established for patients with non-dialysis CKD. This review provides an overview of current and emerging markers and tools used in the diagnosis and management of CKD-MBD in non-dialysis adult patients.

Clonal Hematopoiesis of Indeterminate Potential and Cardiovascular Risk in Patients with Chronic Kidney Disease without Previous Cardiac Pathology

Clonal hematopoiesis of indeterminate potential (CHIP) is defined by the clonal expansion of hematopoietic stem cells carrying certain genes associated with an increased risk of hematological malignancies. Our study analyzes the influence of CHIP on the risk of heart disease and cardiovascular events in a population with chronic kidney disease (CKD). A total of 128 patients were prospectively followed up for 18 months to detect major cardiovascular events (MACE). To detect the presence of silent heart disease, troponin I, NT-Pro-BNP, and coronary calcification were measured. A massive sequencing was performed to detect CHIP. A total of 24.2% of the patients presented CHIP, including that which was only pathogenic. The most frequently affected gene was TET2 (21.1%). Using multivariate logistic regression analysis, the presence of CHIP was not related to coronary calcification (OR 0.387, 95% CI 0.142-1.058, p = 0.387), nor was it related to troponin I or NT-Pro-BNP. A total of nine patients developed major cardiovascular events. Patients with CHIP did not have a higher risk of major cardiovascular events, although patients with DNMT3A did have a higher risk (HR 6.637, 95% CI 1.443-30.533, p = 0.015), independent of other variables. We did not find that CHIP was associated with a greater risk of silent heart disease or cardiovascular events, although those affected by DNMT3a, analyzed independently, were associated with a greater number of cardiovascular events.

The Role of Two Heart Biomarkers in IgA Nephropathy

Cardiovascular mortality is a leading cause of death in chronic kidney disease (CKD), as is IgA nephropathy (IgAN). The purpose of this study is to find different biomarkers to estimate the outcome of the disease, which is significantly influenced by the changes in vessels (characterized by arterial stiffness) and the heart. In our cross-sectional study, 90 patients with IgAN were examined. The N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was measured as a heart failure biomarker by an automated immonoassay method, while the carboxy-terminal telopeptide of collagen type I (CITP) as a fibrosis marker was determined using ELISA kits. Arterial stiffness was determined by measuring carotid-femoral pulse wave velocity (cfPWV). Renal function and routine echocardiography examinations were performed as well. Based on eGFR, patients were separated into two categories, CKD 1-2 and CKD 3-5. There were significantly higher NT-proBNP (p = 0.035), cfPWV (p = 0.004), and central aortic systolic pressure (p = 0.037), but not CITP, in the CKD 3-5 group. Both biomarker positivities were significantly higher in the CKD 3-5 group (p = 0.035) compared to the CKD 1-2 group. The central aortic systolic pressure was significantly higher in the diastolic dysfunction group (p = 0.034), while the systolic blood pressure was not. eGFR and hemoglobin levels showed a strong negative correlation, while left ventricular mass index (LVMI), aortic pulse pressure, central aortic systolic pressure, and cfPWV showed a positive correlation with NT-proBNP. cfPWV, aortic pulse pressure, and LVMI showed a strong positive correlation with CITP. Only eGFR was an independent predictor of NT-proBNP by linear regression analysis. NT-proBNP and CITP biomarkers may help to identify IgAN patients at high risk for subclinical heart failure and further atherosclerotic disease.

Soluble CD14 and Osteoprotegerin Associate with Ankle-Brachial Index as a Measure of Arterial Stiffness in Patients with Mild-to-Moderate Chronic Kidney Disease in a Five-Year Prospective Study

INTRODUCTION

Vascular lesions and arterial stiffness appear at early stages of chronic kidney disease (CKD) and follow an accelerated course with disease progression, contributing to high cardiovascular mortality. There are limited prospective data on mechanisms contributing to progression of arterial stiffness in mild-to-moderate CKD (stages 2-3).

METHODS

We applied an affinity proteomics approach to identify candidates of circulating biomarkers with potential impact on vascular lesions in CKD and selected soluble cluster of differentiation 14 (sCD14), angiogenin (ANG), and osteoprotegerin (OPG) for further analysis. We studied their association with ankle-brachial index (ABI) and carotid intima-media thickness, as measures of arteriosclerosis and atherosclerosis, respectively, in 48 patients with CKD stages 2-3, who were prospectively followed and intensively treated for 5 years, and 44 healthy controls.

RESULTS

Concentrations of sCD14 (p < 0.001), ANG (p < 0.001), and OPG (p < 0.05) were higher in patients with CKD 2-3 at baseline, and sCD14 (p < 0.001) and ANG (p < 0.001) remained elevated in CKD patients at follow-up. There were positive correlations between ABI and sCD14 levels (r = 0.36, p = 0.01) and between ABI and OPG (r = 0.31, p = 0.03) at 5 years. The changes in sCD14 during follow-up correlated to changes in ABI from baseline to 5 years (r = 0.41, p = 0.004).

CONCLUSION

Elevated levels of circulating sCD14 and OPG in patients with CKD 2-3 were significantly associated with ABI, a measure of arterial stiffness. An increase in sCD14 over time in CKD 2-3 patients was associated with a corresponding increase in ABI. Further studies are needed to examine if early intensive multifactorial medication to align with international treatment targets may influence cardiovascular outcomes.

Developing a Questionnaire on Knowledge, Perceptions and Application of Vascular-Aging Measurements

BACKGROUND

Vascular age (VA) is independent and chronological age for assessing cardiovascular disease (CVD) risk. However, tools for the implementation of VA are currently lacking. We aimed to develop a questionnaire to assess the current knowledge gaps related to VA and barriers to its implementation in routine practice.

METHODS

Using a stepwise mixed-method approach, a quantitative questionnaire was constructed in four phases: (1) basic item generation and the development of a semi-qualitative questionnaire (SQQ); (2) dissemination to the VascAgeNet extended network and an analysis of the semi-qualitative questionnaire responses; (3) the development of a quantitative questionnaire (QQ); and (4) an assessment of the content and face validity and internal reliability in an additional sample.

RESULTS

Based on six main topics initially identified through an expert panel, a SQQ was developed and disseminated. Finally, a 22-item QQ was developed, with questions grouped around three main themes: knowledge of VA and its risk factors; perceptions and beliefs regarding the importance and contribution of VA to risk classification; and the application of VA measurements in clinical and research practice and its potential limitations (Cronbach's alpha between 0.920 and 0.982 for all three categories).

CONCLUSION

We report the development of a QQ on VA addressed to both clinicians and non-clinicians aiming to assess their knowledge, perceptions and application of VA measurements.

Medial artery calcification in peripheral artery disease

Medial artery calcification (MAC) is a distinct, highly regulated process that is often identified in small and mid-sized arteries of the lower extremities. It is associated with advanced age, diabetes, and chronic kidney disease. MAC often occurs in conjunction with atherosclerotic occlusive disease in lower extremity arteries, and when seen together or in isolation, long-term limb outcomes are negatively affected. In patients with peripheral artery disease (PAD), the extent of MAC independently correlates with major amputation and mortality rates, and it predicts poor outcomes after endovascular interventions. It is associated with increased arterial stiffness and decreased pedal perfusion. New endovascular methods aimed at treating calcified lower-extremity lesions may improve our ability to treat patients with limb-threatening ischemia. Although recent developments have increased our understanding of the mechanisms contributing to MAC, further investigations are needed to understand the role of medial calcification in PAD, and to develop strategies aimed at improving patient outcomes.

Portable Device use for Arterial Stiffness Determination as a Control Method at the Recovery Stage of Rehabilitation

Aim: To create a device for PWPV evaluation which would be cheap and could be easily used not only at the inpatient but also at the restorative outpatient and health-resort stages of rehabilitation. Materials and Methods: The clinical examination included 90 people who were randomized into the group of observation (n=75) with patients of AH various degrees. 15 practically healthy persons were involved into the control group. PWPV was measured using a specially designed device according to the generally accepted carotid-femoral technique. Results: Our results showed that the PWPV of healthy persons measured using original device failed to differ statistically from the literature reference values and indicated the correspondence of the measurements we obtained with the data received using traditional apparatus. Out data of original PWPV measurement obtained from examined and treated patients do not differ from the results obtained in wide range of patients aged from 40 to 70 years with the 1st -2nd stages of AH. Conclusions: We described an efficacy of PWPV determination using an original device. The use of the proposed device does not contradict with the generally accepted method of vascular stiffness measuring and studying. The results obtained on it are comparable with the data of the most used stationary device SphygmoCor for these purposes. The prospects of the device using are without the limitations in patients with vascular diseases at the stage of rehabilitation.

Bone Mineral Density and Vascular Calcification in Children and Young Adults With CKD 4 to 5 or on Dialysis

Introduction

Older adults with chronic kidney disease (CKD) can have low bone mineral density (BMD) with concurrent vascular calcification. Mineral accrual by the growing skeleton may protect young people with CKD from extraosseous calcification. Our hypothesis was that children and young adults with increasing BMD do not develop vascular calcification.

Methods

This was a multicenter longitudinal study in children and young people (5-30 years) with CKD stages 4 to 5 or on dialysis. BMD was assessed by tibial peripheral quantitative computed tomography (pQCT) and lumbar spine dual-energy X-ray absorptiometry (DXA). The following cardiovascular imaging tests were undertaken: cardiac computed tomography for coronary artery calcification (CAC), ultrasound for carotid intima media thickness z-score (cIMTz), pulse wave velocity z-score (PWVz), and carotid distensibility for arterial stiffness. All measures are presented as age-adjusted and sex-adjusted z-scores.

Results

One hundred participants (median age 13.82 years) were assessed at baseline and 57 followed up after a median of 1.45 years. Trabecular BMD z-score (TrabBMDz) decreased (P = 0.01), and there was a nonsignificant decrease in cortical BMD z-score (CortBMDz) (P = 0.09). Median cIMTz and PWVz showed nonsignificant increase (P = 0.23 and P = 0.19, respectively). The annualized increase in TrabBMDz (ΔTrabBMDz) was an independent predictor of cIMTz increase (R ² = 0.48, β = 0.40, P = 0.03). Young people who demonstrated statural growth (n = 33) had lower ΔTrabBMDz and also attenuated vascular changes compared with those with static growth (n = 24).

Conclusion

This hypothesis-generating study suggests that children and young adults with CKD or on dialysis may develop vascular calcification even as their BMD increases. A presumed buffering capacity of the growing skeleton may offer some protection against extraosseous calcification.

Arterial Stiffness and Chronic Kidney Disease Progression in Children

BACKGROUND AND OBJECTIVES

CKD has been linked to increased arterial stiffness in adults, but data in children with CKD remain conflicting. We aimed to investigate the longitudinal dynamics and determinants of pulse wave velocity in children with CKD and its association with CKD progression.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed an analysis of the Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) study, which prospectively followed children aged 6-17 years with CKD stages 3-5. Follow-up was censored at the time of KRT initiation. Two separate analyses were performed: with absolute pulse wave velocity (primary outcome) and with pulse wave velocity standardized to height (z score; restricted to participants ≤17 years) as a sensitivity analysis.

RESULTS

In total, 667 patients with a mean baseline eGFR of 27 ml/min per 1.73 m2 were included. Pulse wave velocity above the 95th percentile was observed in 124 (20%) patients at baseline. Absolute pulse wave velocity increased gradually over the median follow-up of 2.7 (interquartile range, 0.7-4.4) years, whereas pulse wave velocity z score remained relatively stable. Absolute pulse wave velocity over time associated with time; older age; higher mean arterial pressure, LDL cholesterol, and albuminuria; and lower ferritin. Pulse wave velocity z score (n=628) was associated with the same variables and additionally, with higher diastolic BP z score, lower height z score, younger age, and girls. Of 628 patients, 369 reached the composite end point of CKD progression (50% eGFR loss, eGFR <10 ml/min per 1.73 m2, or the start of KRT) during a median follow-up of 2.4 (interquartile range, 0.9-4.6) years. Pulse wave velocity z score did not associate with CKD progression by univariable or multivariable proportional hazard analysis correcting for the established predictors eGFR, proteinuria, and BP.

CONCLUSIONS

Pulse wave velocity is increased in children with CKD but does not associate with eGFR or CKD progression.

Coronary and extra-coronary artery calcium scores as predictors of cardiovascular events and mortality in chronic kidney disease stages 1-5: a prospective cohort study

BACKGROUND

Vascular calcification is a known risk factor for cardiovascular events and mortality in patients with chronic kidney disease (CKD). However, since there is a lack of studies examining several arterial regions at a time, we aimed to evaluate the risk of major adverse cardiovascular events (MACE) and all-cause mortality according to calcium scores in five major arterial sites.

METHODS

This was a prospective study of 580 patients from the Copenhagen CKD Cohort. Multidetector computed tomography of the coronary and carotid arteries, the thoracic aorta, the abdominal aorta, and the iliac arteries was used to determine vascular calcification at baseline. Calcium scores were divided into categories: 0, 1-100, 101-400, and > 400.

RESULTS

During the follow-up period of 4.1 years a total of 59 cardiovascular events and 64 all-cause deaths occurred. In Cox proportional hazards models adjusted for age, sex, eGFR, hypertension, diabetes mellitus, hypercholesterolemia, and smoking, only the coronary and carotid arteries, and the thoracic aorta were independent predictors of the designated endpoints. When examining the potential of calcification in the five arterial sites for predicting MACE, the difference in C-statistic was also most pronounced in these three sites, 0.21 (95% CI 0.16%-0.26%, P < 0.001), 0.26 (95% CI 0.22%-0.3%, P < 0.001), and 0.20 (95% CI 0.16%-0.24%, P < 0.001), respectively. This trend also applied to all-cause mortality.

CONCLUSIONS

The overall results, including data on specificity, suggest that calcium scores of the coronary and carotid arteries have the most potential for identifying patients with CKD at high cardiovascular risk and for evaluating new therapies.

Evaluating the association between amino acid and acylcarnitine profiles and different levels of coronary artery disease risk in postmenopausal women using targeted metabolomics technique

OBJECTIVES

Postmenopausal women are at increased risk of developing coronary artery disease (CAD). Metabolomic approaches aim at discovering more helpful biomarkers of CAD to reduce the disease burden in the future. Here, we intend to find potential blood biomarkers, amino acids, and acylcarnitines in postmenopausal women with different severity of CAD by using high-throughput methods.

METHOD

This cross-sectional study was performed on postmenopausal women ( n = 183) who underwent coronary CT scans. Coronary artery calcium scoring (CACS) was assessed to detect plaque burden and degree of coronary artery obstruction. The participants were divided into three groups based on the score as follows (i) "low CACS" ( n = 96); a score of 0 to 10, (ii) "medium CACS" ( n = 35); a score between 11 and 100 and (iii) "high CACS" ( n = 52); a score greater than 100. Metabolites, including amino acids and acylcarnitines, were quantified using a targeted mass spectrometry method in serum samples. The association between metabolites and disease status was evaluated using univariate and multivariate regression analyses with adjustment for confounding factors. Factor analysis was used to deal with multiple comparisons.

RESULTS

Metabolites, including proline, glutamic acid, and phenylalanine, were significantly lower in the high CACS group than the low CACS one. Also, a lower level of lysine and phenylalanine in high CACS compared with medium one was observed. Concerning acylcarnitines, it was found that C4 and C8:1 significantly were higher in women with high CACS. The logistic regression analysis revealed that the circulating levels of these metabolites (except C4) were associated with the presence of coronary artery calcification independently of age, body mass index, and time of menopause. Also, the amino acids were associated independently of medication and diabetes.

CONCLUSIONS

The present study indicated that circulating levels of amino acids and acylcarnitines profile in postmenopausal women are partly associated with the severity of CAD in these participants.

Association of atherogenic serum lipids and platelet activation with changes in arterial stiffness in patients with type 2 diabetes

Pulse wave velocity (PWV) is a potential marker for atherosclerosis severity and/or predictor of future atherosclerotic cardiovascular events. PWV is significantly correlated with carotid-intimal media thickness in patients with diabetes. However, its significance as a surrogate marker for the treatment of atherosclerotic cardiovascular risk in the management of type 2 diabetes has not been fully established. To elucidate the factors that determine the improvement or deterioration of PWV, we studied the association of clinical parameters, parameters for glucose metabolism, serum lipids including each lipoprotein fraction, serotonin as a marker for platelet activation, and change in PWV in 54 patients with type 2 diabetes. Systolic blood pressure and serum levels of non-high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol (LDL-C), and intermediate-density lipoprotein-cholesterol significantly decreased in the PWV-improved group after 2 months compared with those in the PWV-deteriorated group. The serotonin levels at baseline were significantly lower in the PWV-improved group than in the PWV-deteriorated group. The changes in systolic blood pressure and LDL-C levels were significantly and positively correlated with those in PWV. The serotonin levels at baseline were significantly and positively correlated with changes in PWV. Therefore, amelioration of blood pressure, serum lipid level, and platelet activation might be beneficially associated with PWV change. PWV-guided clinical practice for cardiovascular risk stratification could be useful in type 2 diabetes management.

Evaluation of Intima-Media Thickness and Arterial Stiffness as Early Ultrasound Biomarkers of Carotid Artery Atherosclerosis

Carotid atherosclerosis is a major and potentially preventable cause of ischemic stroke. It begins early in life and progresses silently over the years. Identification of individuals with subclinical atherosclerosis is needed to initiate early aggressive vascular prevention. Although carotid plaque appears to be a powerful predictor of cardiovascular risk, carotid intima-media thickness (CIMT) and arterial stiffness can be detected at the initial phases and, therefore, they are considered important new biomarkers of carotid atherosclerosis. There is a well-documented association between CIMT and cerebrovascular events. CIMT provides a reliable marker in young people, in whom plaque formation or calcification is not established. However, the usefulness of CIMT measurement in the improvement of risk cardiovascular models is still controversial. Carotid stiffness is also significantly associated with ischemic stroke. Carotid stiffness adds value to the existing risk prediction based on Framingham risk factors, particularly individuals at intermediate cardiovascular risk. Carotid ultrasound is used to assess carotid atherosclerosis. During the last decade, automated techniques for sophisticated analysis of vascular mechanics have evolved, such as speckle tracking, and new methods based on deep learning have been proposed with promising outcomes. Additional research is needed to investigate the imaging-based cardiovascular risk prediction of CIMT and stiffness.

Ambulatory monitoring of central arterial pressure, wave reflections, and arterial stiffness in patients at cardiovascular risk

This paper reviews current 24 h ambulatory noninvasive technologies for pulse wave analysis (PWA) providing central arterial pressure, pulse wave velocity, and augmentation index and the scientific evidence supporting their use in the clinical management of patients with arterial hypertension or at risk for cardiovascular complications.The most outstanding value of these techniques lies in the fact that they are user-friendly, mostly operator independent, and enable the evaluation of vascular function during daily-life conditions, allowing to obtain repeated measurements in different out-of-office circumstances, less artificial than those of the laboratory or doctor's office.Studies performed so far suggest that 24 h PWA may represent a potentially promising tool for evaluating vascular function, structure, and damage in daily-life conditions and promoting early screening in subjects at risk. The current evidence in favor of such an approach in the clinical practice is still limited and does not recommend its routine use. In particular, at the moment, there is a shortage of long-term prognostic studies able to support the predictive value of 24 h PWA. Finally, the accuracy of the measures is strongly dependent on the type of technology and device employed with lack of interoperability among the devices that deeply affects comparability of results among studies using different technologies. It is thus mandatory in the near future to promote proper validation studies, for instance using the ARTERY protocol, and to plan well-designed long-term longitudinal studies that may prove the accuracy and high predictive value of PWA in ambulatory conditions.

The predictive value of coronary artery calcification score combined with bone mineral density for the 2-year risk of cardiovascular events in maintenance hemodialysis patients

PURPOSE

Cardiovascular disease is the leading cause of death in maintenance hemodialysis (MHD) patients. The aim of this study is to investigate the predictive value of coronary artery calcification score (CACs) combined with bone mineral density (BMD) for the risk of cardiovascular diseases in MHD patients.

METHODS

From January 2017 to January 2019, we enrolled 112 MHD patients and 112 controls in Ningbo First Hospital, and retrospectively counted the cardiovascular events in the next 2 years after enrollment. According to the occurrence of cardiovascular events, the MHD patients were divided into CVD group and non-CVD group. The differences of vertebral BMD and CACs between the two groups were compared. ROC curve, Kaplan-Meier curve and Cox regression analyses were used for assess the predictive value of 2-year cardiovascular events in MHD patients.

RESULTS

Among 112 MHD patients, 49 (43.75%) patients had cardiovascular events. The results showed that the average value of BMD in MHD patients was significantly lower than that in the control group (99.88 ± 30.99 VS. 108.35 ± 23.98, P = 0.0231). The CACs in MHD patients were significantly higher than that in the control group (317.81 ± 211.53 VS. 190.03 ± 100.50, P < 0.001). The results between CVD group and the non-CVD group were to the same direction (BMD: 81.12 ± 31.28 VS. 114.48 ± 21.61, P < 0.001; CACs: 447.16 ± 234.11 VS. 217.21 ± 119.03, P < 0.001). Besides, CACs combined with BMD yield an AUC of 0.875 with a sensitivity of 79.60%, a specificity of 82.50%. Kaplan-Meier curve and Cox regression analyses indicated that CACs and BMD were independently associated with high risk of cardiovascular events in MHD patients.

CONCLUSION

The combination of CACs and vertebral BMD could predict the occurrence of cardiovascular events in MHD patients to some extent.

Cardiovascular Risk Assessment Using Ultrasonographic Surrogate Markers of Atherosclerosis and Arterial Stiffness in Patients With Chronic Renal Impairment: A Narrative Review of the Evidence and a Critical View of Their Utility in Clinical Practice

PURPOSE OF THE REVIEW

Validated tools to improve cardiovascular disease (CVD) risk assessment and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are lacking. Noninvasive measures of arteriosclerosis and subclinical atherosclerosis such as pulse wave velocity (PWV) and carotid intima-media thickness (cIMT), respectively, have emerged as promising risk stratification tools and potential modifiable biomarkers. Their wide use as surrogate markers in clinical research studies is based on the strong pathophysiological links with CVD. However, whether their effect as risk stratification or intervention targets is superior to established clinical approaches is uncertain. In this review, we examine the evidence on the utility of PWV, cIMT, and plaque assessment in routine practice and highlight unanswered questions from the clinician's perspective.

SOURCES OF INFORMATION

Electronic databases PubMed and Google Scholar were searched until February 2020.

METHODS

This narrative review is based on peer-reviewed meta-analyses, national and international societies' guidelines, and on focused critical review of recent original studies and landmark studies in the field.

KEY FINDINGS

Although patients with CKD are considered in the high-risk CVD groups, there is still need for tools to improve risk stratification and individualized management strategies within this group of patients. Carotid intima-media thickness is associated with all-cause mortality, CVD mortality, and events in CKD and hemodialysis cohorts. However, the evidence that measurement of cIMT has a clinically meaningful role over and above existing risk scores and management strategies is limited. Plaque assessment is a better predictor than cIMT in non-CKD populations and it has been incorporated in recent nonrenal-specific guidelines. In the CKD population, one large observational study provided evidence for a potential role of plaque assessment in CKD similar to the non-CKD studies; however, whether it improves prediction and outcomes in CKD is largely understudied. Pulse wave velocity as a marker of arterial stiffness has a strong pathophysiological link with CVD in CKD and numerous observational studies demonstrated associations with increased cardiovascular risk. However, PWV did not improve CVD reclassification of dialysis patients when added to common risk factors in a reanalysis of ESRD cohorts with available PWV data. Therapeutic strategies to regress PWV, independently from blood pressure reduction, have not been studied in well-conducted randomized trials.

LIMITATIONS

This study provides a comprehensive review based on extensive literature search and critical appraisal of included studies. Nevertheless, formal systematic literature review and quality assessment were not performed and the possibility of selection bias cannot be excluded.

IMPLICATIONS

Larger, prospective, randomized studies with homogeneous approach, designed to answer specific clinical questions and taking into consideration special characteristics of CKD and dialysis, are needed to study the potentially beneficial role of cIMT/plaque assessment and PWV in routine practice.