Progression of aortic arch calcification over 1 year is an independent predictor of mortality in incident peritoneal dialysis patients

The impact of accessibility to non-calcium-based phosphate binders and calcimimetics on mineral outcomes in patients receiving maintenance hemodialysis: A 10-year retrospective analysis of real-world data

INTRODUCTION

Hyperphosphatemia and hyperparathyroidism are common in end-stage kidney disease and are associated with poor outcomes. In addition to adequate dialysis, medications are usually required for optimum control of serum phosphate and parathyroid hormone (PTH) levels. The use of calcium-based phosphate binders (CBPBs) and active vitamin D is associated with an increase in serum calcium and worsening vascular calcification. To overcome these limitations, non-calcium-based phosphate binders (NCBPBs) and calcimimetics have been developed. However, the coverage for these new medications remains limited in several parts of the world due to the lack of patient-level outcome data and cost. The present study examined the differences in mineral outcomes between two main categories of healthcare programs that provided different coverage for medications used to control mineral and bone disorders (MBD). The Social Security/Universal Coverage (SS/UC) program covered only CBPBs and active vitamin D, whereas the Civil Servant/State Enterprise (CS/SE) program provided coverage of CBPBs, active vitamin D, NCBPBs, and calcimimetics.

METHODS

This 10-year retrospective cohort study examined the differences in mineral outcomes between two healthcare programs in maintenance hemodialysis patients. The differences in serum calcium, phosphate, and PTH levels, as well as the aortic arch calcification score, were analyzed according to dialysis vintage by linear mixed-effects regression analyses. The difference in the composite outcome of severe hyperparathyroidism and parathyroidectomy was analyzed by the Cox-proportional hazard regression model.

RESULTS

714 patients were included in the analyses (full cohort). Of these patients, 563 required at least one type of medication to control MBD (MBD medication subgroup). Serum calcium, phosphate, and the proportions of patients with hypercalcemia and hyperphosphatemia were substantially higher in the SS/UC group compared with the CS/SE group after appropriate adjustments for confounders in both the full cohort and the MBD medication subgroup. These findings were confirmed in propensity-score matched analyses. Higher parathyroid hormone levels and a higher rate of the composite endpoint of severe hyperparathyroidism and parathyroidectomy were also observed in the SS/UC group. A more rapid progression of aortic arch calcification was suggested in the SS/UC group, but between-group changes were not significant.

CONCLUSION

Patients under the healthcare program that did not cover the use of NCBPBs and calcimimetics showed higher serum calcium and phosphate levels and a more rapid progression of hyperparathyroidism. The difference in the progression of vascular calcification could not be confirmed in the present study.

Analysis of factors influencing vascular calcification in peritoneal dialysis patients and their impact on long-term prognosis

BACKGROUND

This study aims to investigate the influencing factors of vascular calcification in peritoneal dialysis (PD) patients and its relationship with long-term prognosis.

METHODS

This retrospective cohort study included chronic kidney disease patients undergoing peritoneal dialysis at the Peritoneal Dialysis Center of Beijing Luhu Hospital, Capital Medical University, from January 2019 to March 2019. Demographic and clinical laboratory data, including serum sclerostin (SOST), calcium (Ca), phosphate (P), serum albumin (ALB), and intact parathyroid hormone (iPTH) levels, were collected. Abdominal aortic calcification (AAC) was assessed using abdominal lateral X-ray examination to determine the occurrence of vascular calcification, and patients were divided into the AAC group and Non-AAC group based on the results.

RESULTS

A total of 91 patients were included in the study. The AAC group consisted of 46 patients, while the Non-AAC group consisted of 45 patients. The AAC group had significantly older patients compared to the non-AAC group (P < 0.001) and longer dialysis time (P = 0.004). Multivariable logistic regression analysis indicated that risk factors for vascular calcification in PD patients included dialysis time, diabetes, hypertension, and SOST. Kaplan-Meier survival analysis showed that the AAC group had a significantly higher mortality rate than the non-AAC group (χ2 = 35.993, P < 0.001). Multivariable Cox regression analysis revealed that dialysis time, diabetes and AAC were risk factors for all-cause mortality in peritoneal dialysis patients.

CONCLUSION

Longer dialysis time, comorbid diabetes, comorbid hypertension, and SOST are risk factors for vascular calcification in PD patients. Additionally, AAC, longer dialysis time, and comorbid diabetes are associated with increased risk of all-cause mortality in peritoneal dialysis patients.

Analysis of risk factors for abdominal aortic calcification in dialysis patients and its influence on long-term recovery

This study investigated the risk factors of abdominal aortic calcification (AAC) in patients with stage 5 chronic kidney disease (CKD) and the effects of AAC and different dialysis methods on the 3-year survival rate of patients with stage 5 CKD. A retrospective cohort study was conducted on stage 5 CKD patients who received dialysis treatment. The general data were collected, and all fasting venous blood samples were harvested before the first dialysis to detect biochemical markers. The AAC was evaluated by lateral abdominal X-ray. The patients were followed up with a cut-off date of March 31, 2022, with all-cause mortality as the endpoint event. A total of 205 patients were included. multivariable Cox regression analysis confirmed that AAC (hazard ratio (HR) = 2.173, 95% CI 1.029-4.588, p = 0.042), advanced age (HR = 1.061, 95% CI 1.031-1.093, p < 0.001), duration of dialysis (HR = 1.015, 95% CI 1.007-1.032, p < 0.001), diabetes (HR = 3.966, 95% CI 2.164-7.269, p < 0.001), and hypertension (HR = 1.897, 95% CI 1.089-3.303, p = 0.024) were independent risk factors for 3-year mortality. However, peritoneal dialysis (HR = 0.366, 95% CI 0.165-0.812, p = 0.013), high albumin (HR = 0.882, 95% CI 0.819-0.950, p = 0.001), and high hemoglobin (HR = 0.969, 95% CI 0.942-0.997, p = 0.031) were protective factors for 3-year mortality in stage 5 CKD patients. Increased age, long-term dialysis, high level of intact parathyroid hormone, diabetes, and hypertension are closely related to the occurrence of AAC in patients with stage 5 CKD. In addition, AAC is an independent risk factor for all-cause mortality in patients with stage 5 CKD.

Aortic arch calcification and risk of all-cause mortality and cardiovascular disease: The Guangzhou Biobank Cohort Study

Background

There were no reports on the associations of aortic arch calcification (AAC) measured by chest X-ray with all-cause mortality and cardiovascular disease (CVD) in older general population. Moreover, previous studies of hemodialysis patients showed that AAC was correlated with left ventricular hypertrophy (LVH) and predicted CVD jointly. Whether the effects remained in the general population is unknown. We examined the associations of AAC with all-cause mortality and CVD in general population and the risk associated with the coexistence of AAC and LVH.

Methods

Presence and severity (grades 0-2) of AAC were measured by chest X-ray, and LVH was identified by 12-lead electrocardiogram in 27,166 Chinese aged 50+ years free of CVD from Guangzhou Biobank Cohort Study. Multivariate Cox regressions were used to examine associations of AAC and LVH with outcomes.

Findings

During an average follow-up of 14·3 years, 5,350 deaths and 4,012 CVD occurred. Compared to those without AAC at baseline, those with AAC had higher risks of all-cause mortality (HR 1·24, 95% CI 1·17-1·31) and CVD (HR 1·22, 95% CI 1·14-1·30), with dose-response relationship (P ≤ 0·001). Furthermore, those with coexistence of AAC and LVH had higher risks of all-cause mortality (HR 1·72, 95% CI 1·37-2·15) and CVD (HR 1·80, 95% CI 1·40-2·32) than those without AAC and LVH.

Interpretation

As chest X-ray has been performed commonly for health screening and in hospital patients when first admitted, AAC measured by chest X-ray can be further applied to assist cardiovascular risk stratification in the community and clinical settings.

Funding

The Natural Science Foundation of China (No. 81941019).

Parathyroidectomy is associated with slow progression of vascular calcification in maintenance haemodialysis patients: A propensity score-matched case-control study

Parathyroidectomy has been the mainstay of treatment of severe hyperparathyroidism in patients with kidney failure until the introduction of calcimimetic. Several large observational studies demonstrated the improvement in patient outcomes after parathyroidectomy. The benefit of parathyroidectomy on vascular calcification remains largely unexplored.

AIM

To examine the association between parathyroidectomy and the progression of vascular calcification as well as overall survival in maintenance haemodialysis patients.

METHOD

This is a matched case-control study undertaken between 2012 and 2020. Patients who underwent parathyroidectomy were identified and matched 1:1 to non-parathyroidectomized (non-PTX) haemodialysis patients using propensity score matching method resulting in 120 patients in each arm. Aortic arch calcification (AoAC) score was determined annually in the posteroanterior chest x-ray. The average follow-up period was 38 months.

RESULTS

Baseline demographic, laboratory data and AoAC score were comparable among the two groups of patients. The prevalence of AoAC was 59% in the PTX group and 54% in the non-PTX group (p = .43). Progression of AoAC occurred in 33% in the PTX group and 47% in the non-PTX group (p = .04). Multivariate generalized linear model revealed parathyroidectomy as an independent protective factor [β (95% CI) -1.04 (-1.68, -0.41)] and increased serum calcium as a potentiating factor [β (95% CI) 0.62 (0.25, 0.1)] for progression of AoAC. Linear mixed models revealed an increase in AoAC score in both groups but between group comparisons indicated substantially slower progression in the PTX group. Rapid progression of AoAC was also observed more frequently among non-PTX patients. Death occurred in 7 and 16% in the PTX and non-PTX groups, respectively. Kaplan-Meier survival curve revealed better survival associated with parathyroidectomy (p = .01). More rapid progression of AoAC also correlated with worse survival.

CONCLUSION

Parathyroidectomy was associated with slow progression of vascular calcification in maintenance haemodialysis patients.

Prognostic Implication of Longitudinal Changes in Cardiothoracic Ratio and Aortic Arch Calcification in Hemodialysis Patients

Patients with end-stage renal disease have a high prevalence of cardiovascular disease. Chest radiography can be used to assess cardiothoracic ratio (CTR) and aortic arch calcification (AoAC). The aims of this longitudinal follow-up study were to investigate factors associated with changes in CTR and AoAC and understand whether these changes are associated with overall and cardiovascular mortality in hemodialysis (HD) patients. We enrolled 260 patients undergoing HD who had at least two available chest X-rays from 2008 to 2015. CTR and AoAC were assessed in each patient using measurements from baseline and annual chest X-rays. The CTR increased from 49.05% to 51.86% and the AoAC score increased from 3.84 to 9.73 over 7 years. The estimated slopes were 0.24 (p < 0.0001) for CTR and 0.08 (p = 0.0441) for AoAC. Increased AoAC, older age, female sex, coronary artery disease, and decreased albumin were associated with an increase in CTR, and older age, cerebrovascular disease, decreased albumin, increased Kt/V, and the use of antiplatelet agents were associated with an increase in AoAC. During follow-up, 136 of the 260 (52.3%) patients died, of whom 72 died due to cardiovascular causes. The change in CTR was greater in those who died (p = 0.0125) than in those who survived. The AoAC score was also higher in those who died than in those who survived, although there was no significant difference in the change in AoAC between the two groups (p = 0.8035). CTR and AoAC increased significantly over time in the HD patients in this longitudinal follow-up study, and the change in CTR was greater in those who died than in those who survived. Chest radiography is a simple and useful tool to assess the progression of CTR and AoAC as a prognostic marker.

Relationship between sex and cardiovascular mortality in chronic kidney disease: A systematic review and meta-analysis

Chronic kidney disease (CKD) is a significant health challenge associated with high cardiovascular mortality risk. Historically, cardiovascular mortality risk has been found to higher in men than women in the general population. However, recent research has highlighted that this risk may be similar or even higher in women than men in the CKD population. To address the inconclusive and inconsistent evidence regarding this relationship between sex and cardiovascular mortality within CKD patients, a systematic review and meta-analysis of articles published between January 2004 and October 2020 using PubMed/Medline, EMBASE, Scopus and Cochrane databases was performed. Forty-eight studies were included that reported cardiovascular mortality among adult men relative to women with 95% confidence intervals (CI) or provided sufficient data to calculate risk estimates (RE). Random effects meta-analysis of reported and calculated estimates revealed that male sex was associated with elevated cardiovascular mortality in CKD patients (RE 1.13, CI 1.03-1.25). Subsequent subgroup analyses indicated higher risk in men in studies based in the USA and in men receiving haemodialysis or with non-dialysis-dependent CKD. Though men showed overall higher cardiovascular mortality risk than women, the increased risk was marginal, and appropriate risk awareness is necessary for both sexes with CKD. Further research is needed to understand the impact of treatment modality and geographical distribution on sex differences in cardiovascular mortality in CKD.

A Decreased Level of Soluble Klotho Can Predict Cardiovascular Death in No or Mild Abdominal Aortic Calcification Hemodialysis Patients

Background: Soluble Klotho plays an important role in cardiovascular disease and death in chronic kidney disease (CKD). We assessed the relationship between serum soluble Klotho (sKL) level and outcome in MHD patients.

Methods: Soluble Klotho was detected by ELISA. Cox regression analysis and Kaplan-Meier analysis showed the relationship between sKL and cardiovascular disease (CVD) mortality in maintenance hemodialysis (MHD) patients.

Results: There were 45 cases (35.2%) of all-cause death and 36 cases (28.1%) of CVD mortality. Multivariate linear regression analysis showed that Log[iPTH] (γ = −0.224, P = 0.015) was an independent predictor of sKL level. Cox regression showed that lower sKL was associated with higher CVD mortality rate [OR = 0.401, 95% CI (0.183–0.867), P = 0.022]. Kaplan-Meier analysis showed that the CVD mortality rate increased significantly in patients with low sKL (P = 0.006). Compared with high sKL patients, low sKL patients with no or mild vascular calcification [aortic calcification score (AACs) ≤ 4] had no significant difference in all-cause mortality rate. The CVD mortality rate was significantly lower in high sKL patients (P = 0.004) than in those with low sKL. In the severe calcification group (AACs ≥ 5), all-cause and CVD mortality rates were similar between different sKL groups (P = 0.706 and 0.488, respectively). The area under the receiver-operating characteristic curve (AUC) of soluble Klotho for predicting the CVD in MHD patients with AACs ≤ 4 was 0.796 (0.647–0.946, P = 0.017), sensitivity was 0.921, and specificity was 0.50 for a cutoff value of 307.69 pg/ml.

Conclusions: Lower sKL was associated with higher CVD mortality rate. Lower sKL concentration in MHD patients with no or mild calcification can predict CVD mortality.

Risk factors for mortality in patients undergoing peritoneal dialysis: a systematic review and meta-analysis

Aim

Inconsistent investigations of the risk factors for all-cause mortality in patients undergoing peritoneal dialysis (PD) were reported. The present meta-analysis aimed to assess the impact of some clinical characteristics on the risk of mortality in PD patients.

Methods

PubMed and Embase were systematically searched for studies evaluating the risk factors for all-cause mortality in PD patients. Hazard ratio (HR) and 95% confidence interval (CI) were derived using a random-effect or fixed-effect model considering the heterogeneity across studies.

Result

A total of 26 studies were included in this meta-analysis in accordance with the inclusion and exclusion criteria. Age, primary cardiovascular diseases, diabetes mellitus, and high level of alkaline phosphatase showed significant positive associations with elevated risk of all-cause and cardiovascular mortality in PD patients, while hemoglobin acted as a benefit factor. Furthermore, early onset of peritonitis, high peritoneal transport status, elevated body mass index and high-sensitivity C-reactive protein could also considerably increase the risk of all-cause mortality. The absolute serum level of magnesium, potassium, and uric acid required to improve survival in PD patients should be verified further.

Conclusions

Multiple factors could affect the risk of mortality in PD patients.

Progression of Aortic Arch Calcification Is Associated with Overall and Cardiovascular Mortality in Hemodialysis

Background

Vascular calcification is common and associated with unfavorable outcomes among patients with end-stage renal disease (ESRD). Nevertheless, little is known whether the progression of vascular calcification outweighs the baseline calcification in association with overall and cardiovascular (CV) mortality in hemodialysis (HD) patients.

Methods

This study included 140 maintenance HD patients. Vascular calcification was assessed using the aortic arch calcification (AoAC) score measured from chest radiographs at the baseline and the second year of follow-up. Progression of vascular calcification (ΔAoAC) was defined as the difference between the two measurements of AoAC. The association of ΔAoAC with overall and CV mortality was evaluated using multivariate Cox regression analysis.

Results

During the mean follow-up period of 5.8 years, there were 49 (35%) overall mortality and 27 (19.3%) CV mortality. High brachial-ankle pulse wave velocity was positively correlated with ΔAoAC, whereas old age was negatively correlated with ΔAoAC. In multivariate adjusted Cox analysis, increased ΔAoAC (per 1 unit), but not baseline AoAC, was significantly associated with overall mortality (HR, 1.183; 95% CI, 1.056–1.327; p = 0.004) and CV mortality (HR, 1.194; 95% CI, 1.019–1.398; p = 0.028).

Conclusion

Progression of AoAC outperformed the baseline AoAC in association with increased risk of overall and CV mortality in HD patients. A regular follow-up of chest radiograph and AoAC score assessments are simple and cost-effective to identify the high-risk individuals of unfavorable outcomes in maintenance HD patients.

Abdominal aortic calcification is superior to other arteries calcification in predicting the mortality in peritoneal dialysis patients - a 8 years cohort study

BACKGROUND

In recent years, there has been a growing concern that abdominal aortic calcification (AAC) has a predictive effect on the prognosis of patients with end-stage renal disease (ESRD). However, whether other vascular calcification (VC) can predict the occurrence of adverse events in patients, and whether it is necessary to assess the calcification of other blood vessels remains controversial. This study aimed to assess VC in different sites using X-ray films, and to investigate the predictive effects of VC at different sites on all-cause mortality and cardiovascular (CV) mortality in peritoneal dialysis (PD) patients.

METHODS

The data of Radiographs (lateral abdominal plain film, frontal pelvic radiograph and both hands radiograph) were collected to evaluate the calcification of abdominal aorta, iliac artery, femoral artery, radial artery, and finger arteries. Patients' demographic data, clinical characteristics, laboratory data were recorded. The total follow-up period was 8 years, and the time and cause of death were recorded. Survival curves were estimated using Kaplan-Meier analysis. COX regression analysis was used to examine independent predictors of all-cause mortality and CV mortality.

RESULTS

One hundred fifty PD patients were included, a total of 79 patients (52.7%) died at the end of follow-up. After adjusting variables in the multivariate COX regression analysis, AAC was an independent predictor of all-cause mortality in PD patients (HR = 2.089, 95% CI: 1.089-4.042, P = 0.029), and was also an independent predictor of CV mortality (HR = 4.660, 95% CI: 1.852-11.725, P = 0.001). We also found that femoral artery calcification had a predictive effect on all-cause and CV mortality. But the calcification in iliac artery, radial artery, and finger arteries were not independent predictors of patients' all-cause and CV mortality in PD patients.

CONCLUSION

AAC was more common in PD patients and was an independent predictor of all-cause mortality and CV mortality. The femoral artery calcification also can predict the mortality, but the calcification of iliac artery, radial artery, and finger arteries cannot predict the mortality of PD patients.

Effect of spironolactone on the progression of coronary calcification in peritoneal dialysis patients: a pilot study

INTRODUCTION

There is evidence that aldosterone plays a role in the pathogenesis of vascular calcification. The aim of this study was to evaluate the effect of spironolactone, a mineralocorticoid receptor antagonist, on the progression of coronary calcification (CC) in peritoneal dialysis patients and to identify the factors involved in this progression.

METHODS

Thirty-three patients with a coronary calcium score (CCS) ≥ 30, detected through multi-detector computed tomography (MDCT) and expressed in Agatston units, were randomly assigned to a group receiving 25mg spironolactone per day for 12 months (spironolactone group) and a control group not receiving this drug. The primary outcome was a percentage change in CCS from baseline to end of the study (relative progression), when a further MDCT was conducted. Patients who had progression of CC were compared with those who did not progress.

RESULTS

Sixteen patients, seven in the spironolactone group and nine in the control group, concluded the study. The relative progression of the CCS was similar in both groups, 17.2% and 27.5% in the spironolactone and control groups respectively. Fifty-seven percent of the treated patients and 67% of those in the control group presented progression in the CC scores (p = 0.697). Progressor patients differed from non-progressors because they presented higher levels of calcium and low-density lipoprotein cholesterol and lower levels of albumin.

CONCLUSION

In peritoneal dialysis patients, spironolactone did not attenuate the progression of CC. However, large-scale studies are needed to confirm this observation. Disorders of mineral metabolism and dyslipidemia are involved in the progression of CC.

Malnutrition, inflammation, progression of vascular calcification and survival: Inter-relationships in hemodialysis patients

Background and aims

Malnutrition and inflammation are closely linked to vascular calcification (VC), the severity of which correlate with adverse outcome. However, there were few studies on the interplay between malnutrition, inflammation and VC progression, rather than VC presence per se. We aimed to determine the relationship of malnutrition, inflammation, abdominal aortic calcification (AAC) progression with survival in hemodialysis (HD) patients.

Methods

Malnutrition and inflammation were defined as low serum albumin (< 40 g/L) and high hs-CRP (≥ 28.57 nmol/L), respectively. We defined AAC progression as an increase in AAC score using lateral lumbar radiography at both baseline and one year later. Patients were followed up to investigate the impact of AAC progression on all-cause and cardiovascular mortality.

Results

AAC progressed in 54.6% of 97 patients (mean age 58.2±11.7 years, 41.2% men) at 1-year follow-up. Hypoalbuminemia (Odds ratio 3.296; 95% confidence interval 1.178–9.222), hs-CRP (1.561; 1.038–2.348), low LDL-cholesterol (0.976; 0.955–0.996), and the presence of baseline AAC (10.136; 3.173–32.386) were significant risk factors for AAC progression. During the mean follow-up period of 5.9 years, 38(39.2%) patients died and 27(71.0%) of them died of cardiovascular disease. Multivariate Cox regression analysis adjusted for old age, diabetes, cardiovascular history, and hypoalbuminemia determined that AAC progression was an independent predictor of all-cause mortality (2.294; 1.054–4.994).

Conclusions

Malnutrition and inflammation were significantly associated with AAC progression. AAC progression is more informative than AAC presence at a given time-point as a predictor of all-cause mortality in patients on maintenance HD.

The relationship between poor nutritional status and progression of aortic calcification in patients on maintenance hemodialysis

Background

Although aortic calcification has a significant negative impact on prognosis in patients on hemodialysis (HD), risk factors for aortic calcification progression remain unclear. The aim of this study was to investigate the relationship between malnutrition and aortic calcification progression in patients on HD.

Methods

Between April 2015 and October 2016, we treated 232 patients on HD. Of those, we retrospectively evaluated data from 184 patients who had had regular blood tests and computed tomography (CT) scans. The abdominal aortic calcification index (ACI) was quantitatively measured by abdominal CT. Nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI). A normalized treatment ratio of functional urea clearance was evaluated by Kt/V. The difference in ACI values between 2015 and 2016 was evaluated as a ΔACI, and patients were stratified into two groups according to ΔACI value: high (≥75th percentile, ΔACI-high group) and low (<75th percentile, ΔACI-low group). Variables such as age, sex, comorbidities, dialysis vintage, serum data, and GNRI were compared between ΔACI-high and ΔACI-low patients. Factors independently associated with a higher ΔACI progression (ΔACI ≥75th percentile) were determined using multivariate logistic analysis.

Results

Median values of ACIs in 2015 and 2016 were 40.8 and 44.6%, respectively. Of 184 patients, 125 (68%) patients experienced ACI progression for 1 year. The median ΔACI and 75th percentile of ΔACI were 2.5% and 5.8%, respectively. The number of patients in the ΔACI-low and ΔACI-high groups were 128 (70%) and 56 (30%), respectively. There were significant differences in sex, presence of diabetic nephropathy, HD vintage, serum albumin, serum phosphate, C-reactive protein, intact parathyroid hormone, Kt/V, and GNRI. Multivariate logistic regression analysis revealed that independent factors associated with a higher ΔACI progression were male sex, serum phosphate levels, HD vintage, and GNRI of < 90.

Conclusions

Our results suggest that poor nutritional status is an independent risk factor for the progression of aortic calcification. Nutrition management may have the potential to improve progression of aortic calcification in patients on HD.

Trial registration

UMIN Clinical Trials Registry UMIN000028050.

Risk of cardiovascular mortality predicted by the serum calcium level and calcification score at the initiation of dialysis

BACKGROUND

The relationship between serum corrected calcium (CCa) level and vessel calcification at dialysis initiation and survival has seldom been evaluated. Therefore, we evaluated the efficacy of CCa levels and the calcification score at the initiation of dialysis for predicting all-cause and cardiovascular (CV) mortality in patients with end-stage renal disease (ESRD).

METHODS

The study group included 407 patients with ESRD, who started hemodialysis between January 2009 and December 2016 at the Red Cross Ishinomaki Hospital. The primary outcomes were the 1- and 3-year all-cause and CV mortality rate, with the association between CCa level and CVD-specific mortality evaluated using the Kaplan-Meier method and Cox proportional hazard regression analysis.

RESULTS

Patients with a high initial CCa level were at higher risk for CVD-related, but not all-cause, mortality than patients with a low initial CCa level [hazard ratio (HR) 2.81; 95% confidence interval 1.05-7.55]. The HR for CVD-related mortality was also higher for patients with an Agatston vessel calcification score > 2000 (HR 13.9; 95% CI 1.63-118.2). Overall, the 3-year CVD-free rate was 88.2% (range 76.4-94.3%). Higher CCa level was associated with a higher Agatston score and cardiac valve calcification.

CONCLUSION

High serum CCa levels and an Agatston score > 2000 are independent risk factors of CVD mortality due to advanced vessel calcification.

Circulating MicroRNA-125b Predicts the Presence and Progression of Uremic Vascular Calcification

OBJECTIVE

Vascular calcification (VC) is a major cause of mortality in patients with end-stage renal diseases. Biomarkers to predict the progression of VC early are in urgent demand.

APPROACH AND RESULTS

We identified circulating, cell-free microRNAs as potential biomarkers using in vitro VC models in which both rat and human aortic vascular smooth muscle cells were treated with high levels of phosphate to mimic uremic hyperphosphatemia. Using an Affymetrix microRNA array, we found that miR-125b and miR-382 expression levels declined significantly as biomineralization progressed, but this decline was only observed for miR-125b in the culture medium. A time-dependent decrease in aortic tissue and serum miR-125b levels was also found in both ex vivo and in vivo renal failure models. We examined the levels of circulating, cell-free miR-125b in sera from patients with end-stage renal diseases (n=88) and found an inverse association between the severity of VC and the circulating miR-125b level, irrespective of age or mineral-related hormones (odds ratio, 0.71; P=0.03). Furthermore, serum miR-125b levels on enrollment can predict VC progression years later (for high versus low, odds ratio, 0.14; P<0.01; for the highest versus lowest tertile and middle versus lowest tertile, odds ratio, 0.55 and 0.13; P=0.3 and <0.01, respectively). The uremic VC prediction efficacy using circulating miR-125b levels was also observed in an independent cohort (n=135).

CONCLUSIONS

The results suggest that serum miR-125b levels are associated with VC severity and serve as a novel predictive marker for the risk of uremia-associated calcification progression.

Role of different imaging modalities of vascular calcification in predicting outcomes in chronic kidney disease

Vascular calcification (VC) is common among patients with chronic kidney disease (CKD). The severity of VC is associated with increased risk of cardiovascular events and mortality. Risk factors for VC include traditional cardiovascular risk factors as well as CKD-related risk factors such as increased calcium and phosphate load. VC is observed in arteries of all sizes from small arterioles to aorta, both in the intima and the media of arterial wall. Several imaging techniques have been utilized in the evaluation of the extent and the severity of VC. Plain radiographs are simple and readily available but with the limitation of decreased sensitivity and subjective and semi-quantitative quantification methods. Mammography, especially useful among women, offers a unique way to study breast arterial calcification, which is largely a medial-type calcification. Ultrasonography is suitable for calcification in superficial arteries. Analyses of wall thickness and lumen size are also possible. Computed tomography (CT) scan, the gold standard, is the most sensitive technique for evaluation of VC. CT scan of coronary artery calcification is not only useful for cardiovascular risk stratification but also offers an accurate and an objective analysis of the severity and progression.

Aortic arch calcification and risk of cardiovascular or all-cause and mortality in dialysis patients: A meta-analysis

Studies on aortic arch calcification (AAC) and mortality risk in maintenance dialysis patients have yielded conflicting findings. We conducted this meta-analysis to investigate the association between the presence of AAC and cardiovascular or all-cause and mortality risk in maintenance dialysis patients. Observational studies evaluating baseline AAC and cardiovascular or all-cause mortality risk in maintenance dialysis patients were searched through the PubMed and Embase, CNKI, VIP and Wanfang databases until January 2016. A total of 8 studies with 3,256 dialysis patients were identified. Compared with patients without AAC, the presence of AAC was associated with greater risk of cardiovascular mortality (hazard risk [HR] 2.30; 95% confidence intervals [CI] 1.78-2.97) and all-cause mortality (HR 1.44; 95% CI 1.19-1.75). Subgroup analyses indicated that the pooled HR for cardiovascular and all-cause mortality was 2.31 (95% CI 1.57-3.40) and 1.45 (95% CI 1.08-1.96) for the grade 2/3 AAC. Peritoneal dialysis patients with AAC had greater cardiovascular (HR 3.93 vs. HR 2.10) and all-cause mortality (HR 2.36 vs. HR 1.33) than hemodialysis patients. The AAC appears to be independently associated with excessive cardiovascular and all-cause mortality in maintenance dialysis patients. Regular follow-up AAC might be helpful to stratify mortality risk in dialysis patients.

Association of Ankle-Brachial Index and Aortic Arch Calcification with Overall and Cardiovascular Mortality in Hemodialysis

Peripheral artery occlusive disease and vascular calcification are highly prevalent in hemodialysis (HD) patients, however the association of the combination of ankle-brachial index (ABI) and aortic arch calcification (AoAC) with clinical outcomes in patients undergoing HD is unknown. In this study, we investigated whether the combination of ABI and AoAC is independently associated with overall and cardiovascular mortality in HD patients. The median follow-up period was 5.7 years. Calcification of the aortic arch was assessed by chest X-ray. Forty-seven patients died including 24 due to cardiovascular causes during the follow-up period. The study patients were stratified into four groups according to an ABI < 0.95 or ≥0.95 and an AoAC score of >4 or ≤4 according to receiver operating characteristic curve. Those with an ABI < 0.95 and AoAC > 4 (vs. ABI ≥ 0.95 and AoAC score ≤ 4) were associated with overall (hazard ratio [HR], 4.913; 95% confidence interval [CI], 1.932 to 12.497; p = 0.001) and cardiovascular (HR, 3.531; 95% CI, 1.070 to 11.652; p = 0.038) mortality in multivariable analysis. The combination of a low ABI and increased AoAC was associated with increased overall and cardiovascular mortality in patients undergoing HD.

Low serum intact parathyroid hormone level is an independent risk factor for overall mortality and major adverse cardiac and cerebrovascular events in incident dialysis patients

Abnormal bone dynamics is a major risk factor for cardiovascular disease in patients with chronic kidney disease. The level of serum intact parathyroid hormone (iPTH) is widely used as a bone dynamic marker. We investigated the effect of the mean level of serum iPTH on overall mortality and cardiovascular outcomes in incident dialysis patients.

PURPOSE

Chronic kidney disease-mineral bone disorder (CKD-MBD) is a major risk factor for cardiovascular disease (CVD) in patients with end-stage renal disease (ESRD). CKD-MBD is classified as low- or high-turnover bone disease according to the bone dynamics; both are related to vascular calcification in ESRD. To evaluate the prognostic value of abnormal serum parathyroid hormone (PTH) levels on ESRD patients, we investigated the effects of time-averaged serum intact PTH (TA-iPTH) levels on overall mortality and major adverse cardiac and cerebrovascular events (MACCEs) in incident dialysis patients.

METHODS

Four hundred thirteen patients who started dialysis between January 2009 and September 2013 at Yonsei University Health System were enrolled. The patients were divided into three groups according to TA-iPTH levels during the 12 months after the initiation of dialysis: group 1, <65 pg/ml; group 2, 65-300 pg/ml; and group 3, >300 pg/ml. Cox regression analyses were performed to determine the prognostic value of TA-iPTH for overall mortality and MACCEs.

RESULTS

The mean age of the patients was 57 ± 15 years, and 222 patients (54 %) were men. During the median follow-up of 40.8 ± 29.3 months, 49 patients (12 %) died, and MACCEs occurred in 55 patients (13 %). The multivariate Cox regression analyses demonstrated that a low TA-iPTH level was an independent risk factor for both overall mortality (group 2 as reference; group 1: hazard ratio (HR) = 2.06, 95 % confidence interval (CI) = 1.11-3.83, P = 0.023) and MACCEs (HR = 1.82, 95 % CI = 1.04-3.20, P = 0.036) in incident dialysis patients after adjustment for confounding factors.

CONCLUSION

Low serum TA-iPTH is a useful clinical marker of both overall mortality and MACCEs in patients undergoing incident dialysis, mediated by vascular calcification.

Severe aortic arch calcification predicts mortality in patients undergoing peritoneal dialysis

BACKGROUND/PURPOSE

Vascular calcification can predict cardiovascular (CV) morbidity and mortality in patients with end-stage renal disease. We evaluated the prevalence, association factors, and outcomes of chest X-ray-detected aortic arch calcification (AoAC) in patients undergoing peritoneal dialysis (PD).

METHODS

We included 190 patients undergoing PD (mean age, 52.6 ± 14.3 years) for whom chest radiographs were available. AoAC revealed by chest X-ray was graded from 0 to 3 according to an AoAC score (AoACS). Multiple regression analyses were used to determine the factors associated with AoACS. After adjusting for age, sex, PD duration, diabetes mellitus, mean blood pressure, and history of CV disease, the association between AoAC grading and mortality were assessed using the Kaplan-Meier curve and Cox proportional hazard model.

RESULTS

Age (p < 0.001), PD duration (p = 0.004), history of CV disease (p < 0.001), and renal Kt/V (p = 0.031) were associated with AoACS. After a mean follow-up of 55.1 ± 32.1 months, patients with Grade 2 (p = 0.011) or Grade 3 (p < 0.001) AoAC had higher all-cause mortality than patients with Grade 0 AoAC. In addition, patients with Grades 2 and 3 AoAC had higher CV-related mortality than those with Grades 0 and 1 AoAC (p = 0.013). Grade 2 [hazard ratio (HR) = 2.736; 95% confidence interval (CI), 1.038-7.211; p = 0.042] and Grade 3 AoAC (HR = 3.289; 95% CI, 1.156-9.359; p = 0.026) remained associated with all-cause mortality after adjustment. Similarly, Grades 2 and 3 AoAC (HR = 36.05; 95% CI, 3.494-372; p = 0.026) significantly correlated with CV mortality after adjustment.

CONCLUSION

In patients undergoing PD, CXR-detected severe AoAC was an independent risk factor for all-cause and CV mortalities.

Association of Brachial-Ankle Pulse Wave Velocity and Cardiomegaly With Aortic Arch Calcification in Patients on Hemodialysis

Aortic arch calcification (AoAC) is associated with cardiovascular and all-cause mortality in end-stage renal disease population. AoAC can be simply estimated with an AoAC score using plain chest radiography. The objective of this study is to evaluate the association of AoAC with brachial-ankle pulse wave velocity (baPWV) and cardiomegaly in patients who have undergoing hemodialysis (HD).We retrospectively determined AoAC and cardiothoracic ratio (CTR) by chest x-ray in 220 HD patients who underwent the measurement of baPWV. The values of baPWV were measured by an ankle-brachial index-form device. Multiple stepwise logistic regression analysis was used to identify the factors associated with AoAC score >4.Compared patients with AoAC score ≦4, patients with AoAC score >4 had older age, higher prevalence of diabetes and cerebrovascular disease, lower diastolic blood pressure, higher baPWV, higher CTR, higher prevalence of CTR ≧50%, lower total cholesterol, and lower creatinine level. After the multivariate stepwise logistic analysis, old age, cerebrovascular disease, high baPWV (per 100 cm/s, odds ratio [OR] 1.065, 95% confidence interval [CI] 1.003-1.129, P = 0.038), CTR (per 1%, OR 1.116, 95% CI 1.046-1.191, P = 0.001), and low total cholesterol level were independently associated with AoAC score >4.Our study demonstrated AoAC severity was associated with high baPWV and high CTR in patients with HD. Therefore, we suggest that evaluating AoAC on plain chest radiography may be a simple and inexpensive method for detecting arterial stiffness in HD patients.

Association between serum vitamin D levels and subclinical coronary atherosclerosis and plaque burden/composition in young adult population

Evidence suggests that low 25-OH vitamin D 25(OH)D concentrations may increase the risk of several cardiovascular diseases such as hypertension, peripheral vascular disease, diabetes mellitus, obesity, myocardial infarction, heart failure and cardiovascular mortality. Recent studies suggested a possible relationship between vitamin D deficiency and increased carotid intima-media wall thickness and vascular calcification. We hypothesized that low 25(OH)D may be associated with coronary atherosclerosis and coronary plaque burden and composition, and investigated the relationship between serum vitamin D levels and coronary atherosclerosis, plaque burden or structure, in young adult patients by using dual-source 128x2 slice coronary computed tomography angiography (CCTA). We included 98 patients with coronary atherosclerosis and 110, age and gender matched, subjects with normal findings on CCTA examinations. Patients with subclinical atherosclerosis had significantly higher serum total cholesterol, triglycerides, hs-CRP, uric acid, HbA1c and creatinine levels and lower serum 25(OH)D levels in comparison with controls. There was no significant correlation between 25(OH)D and plaque morphology. There was also a positive relationship between 25(OH)D and plaque burden of coronary atherosclerosis. In multivariate analysis, coronary atherosclerosis was associated high hs-CRP (adjusted OR: 2.832), uric acid (adjusted OR: 3.671) and low 25(OH)D (adjusted OR: 0.689). Low levels of 25(OH)D were associated with coronary atherosclerosis and plaque burden, but there was no significant correlation between 25(OH)D and plaque morphology.

Aortic arch calcification predicts the renal function progression in patients with stage 3 to 5 chronic kidney disease

Introduction. The presence of aortic arch calcification (AoAC) and cardiomegaly on chest radiography has been demonstrated as important risk factors for cardiovascular mortality in patients with chronic kidney disease (CKD). However, the interrelationship among AoAC, cardiomegaly, and renal function progression remains unclear. The aim of this study is to assess whether AoAC and cardiomegaly are independently associated with the renal function progression in patients with stages 3–5 CKD. Methods. We retrospectively determined AoAC and cardiomegaly by chest X-ray in 237 patients, followed up for at least three years without entering dialysis and classified into 4 groups according to the presence or absence of AoAC and cardiomegaly. The change in renal function was measured by the slope of estimated glomerular filtration rate (eGFR). Results. Of the 237 patients, the rate of eGFR decline was significantly higher in the group with coexistence of AoAC and cardiomegaly than any other groups. Baseline AoAC and proteinuria were independently associated with eGFR decline. AoAC were independently determined by age, eGFR slope, and cardiomegaly. Conclusions. The coexistence of AoAC and cardiomegaly is associated with faster eGFR decline. AoAC is an independent determinant of renal outcomes in patients with CKD stages 3–5.

Aortic arch calcification predicts cardiovascular and all-cause mortality in maintenance hemodialysis patients

BACKGROUND/AIM

Vascular calcification is associated with cardiovascular risk in maintenance hemodialysis (MHD) patients. Previous reports have shown that simple assessment of aortic arch calcification (AoAC) using plain radiography is associated with cardiovascular mortality in the general population. We conducted a prospective study to investigate factors associated with the presence at baseline and progression of AoAC in MHD patients and examined its prognostic value in a short-term outcome.

METHODS

We prospectively evaluated chest X-rays in 301 asymptomatic MHD patients. The extent of AoAC was divided into three Grades (0, 1, 2+3). Demographic data including age, gender, dialysis vintage, co-morbidity and biochemical data were assessed and the patients were then followed for 3 years.

RESULTS

AoAC was observed in 126 patients (41.9%) as Grade 0, in 112 patients (37.2%) as Grade 1, and in 63 patients (20.9%) as Grade 2 and 3 at baseline. An increase in the severity of calcification was associated with older male patients who had lower serum albumin levels. During the follow-up period of 3 years, multivariate Cox proportional hazards analysis revealed that high-grade calcification was associated with cardiovascular and all-cause mortality. Patients with AoAC were associated with a worse outcome in survival analysis and the grade of AAC also influenced their survival. Moreover, all-cause death rates were significantly higher in the progression groups than in the non-progression groups.

CONCLUSIONS

The presence and progression of AoAC assessed by chest X-ray were independently associated with mortality in MHD patients. Regular follow-up by chest X-ray could be a simple and useful method to stratify mortality risk in MHD patients.

Is the dialysate calcium concentration of 1.75 mmol/L suitable for Chinese patients on maintenance hemodialysis?

We studied the effects of increasing the dialysate calcium concentration (DCa) to 1.75 mmol/L on controlling chronic kidney disease-mineral and bone disorder in Chinese patients on maintenance hemodialysis (MHD). We reviewed the data of MHD patients in one center (cohort 1) during prior 10 years and analyzed the risk factors of mortality and transference calcification (TC) in120 MHD patients surviving in 2003 (cohort 2). A multicenter, prospective, parallel-group, controlled trial (cohort 3) was also conducted from January 2011 to December 2012. The DCa at one center was increased from 1.5 to 1.75 mmol/L but was not changed at the other two centers. The clinical outcomes, biochemical parameters, medicine treatments, and TC markers [aortic arch calcification score (AoACS)] were compared between groups. In cohort 1, the annual mean serum iPTH increased significantly over 10 years. In cohort 1, 72 patients survived for 10 years, whose doses of calcium salts and active vitamin D3 and AoACs increased progressively. In cohort 2, the main cause of death was cardiocerebrovascular disease (CCVD) (n = 18, 48.6 %). Male sex and lower serum calcium concentrations were independent risk factors for CCVD mortality. In cohort 3, serum phosphorus, iPTH, and 25(OH)D decreased and serum calcium increased significantly; also, the doses of calcium and vitamin D3 decreased from 2011 to 2012 in the DCa 1.75 group. There were no significant differences in clinical outcomes either between groups or between the two calendar years. Our results indicate that increasing DCa to 1.75 mmol/L can decrease the elevated levels of serum iPTH and phosphorus, reduce the doses of calcium and vitamin D3, and be safe for short periods of time.

Calcification of the aortic arch predicts cardiovascular and all-cause mortality in chronic hemodialysis patients

BACKGROUND

Cardiovascular calcification represents a marker of cardiovascular risk in chronic dialysis patients. In the general population, aortic arch calcification (AAC) can predict cardiovascular mortality. We conducted a prospective study to investigate factors associated with AAC in hemodialysis patients and examined its prognostic value in long-term outcome.

METHODS

A total of 712 hemodialysis patients were enrolled. AAC was identified on postero-anterior chest X-ray films and classified as grade (Gr.) 0, 1, 2 or 3. Demographic data including age, gender, dialysis vintage, co-morbidity and biochemical data were reviewed and recorded. The patients were followed for 10 years.

RESULTS

AAC was present in 164 patients (23%) as Gr. 1, in 116 patients (16.3%) as Gr. 2 and in 126 patients (17.7%) as Gr. 3. An increase in the severity of calcification was associated with older patients who had lower albumin, higher calcium and glucose levels. During the follow-up period of 10 years, we found that the grade of AAC was directly related to cardiovascular mortality (Gr. 0: 5.3%; Gr. 1: 12.7%; Gr. 2: 18.9%, and Gr. 3: 24.4%; p < 0.05) and all-cause mortality (Gr. 0: 19.9%; Gr. 1: 31.1%; Gr. 2: 44.8%, and Gr. 3: 53.2%; p < 0.001). Multivariate Cox proportional hazards analysis revealed that high-grade calcification was associated with cardiovascular and all-cause mortality. Patients with AAC were associated with a worse outcome in survival analysis. The severity of AAC also influenced their survival.

CONCLUSION

Calcification of the aortic arch detected in plain chest radiography was an important determinant of cardiovascular as well as all-cause mortality in chronic hemodialysis patients. The presence and severity of AAC predicted long-term survival.

Abdominal aortic calcification is not superior over other vascular calcification in predicting mortality in hemodialysis patients: a retrospective observational study

BACKGROUND

KDIGO (Kidney Disease: Improving Global Outcomes) guidelines recommend that a lateral abdominal radiograph should be performed to assess vascular calcification (VC) in dialysis patients. However, abdominal aortic calcification is a prevalent finding, and it remains unclear whether other anatomical areas of VC can predict mortality more accurately.

METHODS

A total of 217 maintenance hemodialysis patients were enrolled at the Sichuan Provincial People's Hospital between July 2010 and March 2011. Radiographs of the abdomen, pelvis and hands were evaluated by a radiologist to evaluate the presence of VC. The correlation between different areas of VC and all-cause or cardiovascular mortality was analyzed using univariate and multivariate models.

RESULTS

The prevalence of VC was 70.0% (152 patients), and most had abdominal aortic calcification (90.1%). During 26 ± 7 months of follow-up, 37 patients died. The VC score was independently associated with patient mortality. VC observed on abdominal radiographs (abdominal aortic calcification) was associated with all-cause mortality in models adjusted for cardiovascular risk factors (HR, 4.69; 95%CI, 1.60-13.69) and dialysis factors (HR, 3.38; 95%CI, 1.18-9.69). VC in the pelvis or hands was associated with all-cause mortality in the model adjusted for dialysis factors. When three combinations of VC in different radiographs were included in models, the presence of abdominal VC was only significantly associated with all-cause mortality in the integrated model. VC in the abdomen and pelvis was associated with all-cause mortality in the model adjusted for cardiovascular factors and the integrated model, but neither was significantly associated with cardiovascular mortality. VC in all radiographs was significantly associated with a more than 6-fold risk of all-cause mortality and a more than 5-fold risk of cardiovascular mortality compared to patients without VC.

CONCLUSIONS

VC in different arteries as shown on radiographs is associated with different levels of risk for mortality. The lateral abdominal radiograph may not be superior to other radiographs for predicting patient outcomes. Further research is needed to elucidate the effects of difference burdens of VC on patient outcomes.