Coronary Artery Calcification Score and the Progression of Chronic Kidney Disease

Endothelial injury is one of the risk factors for the progression of vascular calcification in patients receiving maintenance dialysis

BACKGROUND

Vascular calcification is common and progressive in patients with chronic kidney disease. However, the risk factors associated with the progression of vascular calcification in patients receiving maintenance dialysis have not been fully elucidated. Here, we aimed to evaluate vascular calcification and identify the factors associated with its progression in patients receiving maintenance hemodialysis.

METHODS

This is a prospective longitudinal study that included 374 patients receiving maintenance hemodialysis. The participants received assessments of coronary artery calcification (CAC) and abdominal aortic calcification (AAC), as measured by computed tomography. After the baseline investigation, a 2 years follow-up was performed. We also detected the markers of endothelial injury [E-selectin and soluble intercellular adhesion molecule-1 (sICAM-1)]. Finally, the risk factors affecting the CAC and AAC progression were examined by multivariate logistic regression analysis.

RESULTS

Among 374 patients, the median [interquartile range (IQR)] age was 54.0 (40.0-62.0) years; 59.9% of patients were male. The median (IQR) follow-up time was 1.9 (1.8-2.0) years for all patients. By the end of 2-year follow-up, progression of vascular calcification (including CAC and AAC) was observed in 58.0% of patients. Further, compared with the patients without progression of vascular calcification, the endothelial injury (including E-selectin and sICAM-1) of patients with progression of vascular calcification was markedly enhanced. Moreover, after adjustment for the confounders, endothelial injury was a risk factor for the progression of vascular calcification.

CONCLUSION

The present study indicated that endothelial injury is one of the risk factors for the progression of vascular calcification in patients receiving maintenance hemodialysis.

Correlation between coronary calcification and cardiac structure in non-dialysis patients with chronic kidney disease

AIMS

We aim to explore the correlation between coronary artery calcification (CAC) score (CACS) and cardiac structure and function in chronic kidney disease (CKD) patients, create a clinical prediction model for severe CAC associated with cardiac ultrasound indexes.

METHODS AND RESULTS

The study included 178 non-dialysis CKD patients who underwent CACS testing and collected general information, serological indices, cardiac ultrasound findings and follow-up on renal function, heart failure (HF) manifestations and re-hospitalization. The mean age of participants in the study cohort was 67.4 years; 59% were male, and 66.9% of patients had varying degrees of comorbid CAC. CKD patients with CACS > 100 were older, predominantly male and had a higher proportion of smoking, diabetes and hypertension (P < 0.05) compared with those with CACS = 0 and 0 < CACS ≤ 100, and had higher brain natriuretic peptide, serum magnesium and fibrinogen levels were also higher (P < 0.05). CACS was positively correlated with left atrial inner diameter (LAD), left ventricular end-diastolic inner diameter (LVDd), left ventricular volume at diastole (LVVd), output per beat (SV) and mitral orifice early diastolic blood flow velocity/early mitral annular diastolic myocardial motion velocity (E/e) (P < 0.05). We tested the associations between varying degrees of CAC and HF and heart valve calcification using multivariable-adjusted regression models. The risk of HF in patients with severe CAC was about 1.95 times higher than that in patients without coronary calcification, and the risk of heart valve calcification was 2.46 times higher than that in patients without coronary calcification. Heart valve calcification and HF diagnosis, LAD and LVDd are essential in predicting severe CAC. During a mean follow-up time of 18.26 ± 10.17 months, 65 (36.52%) patients had a composite renal endpoint event, of which 36 (20.22%) were admitted to renal replacement therapy. Patients with severe CAC had a higher risk of progression of renal function, re-admission due to cardiovascular and renal events and more pronounced symptoms of HF (P < 0.05).

CONCLUSIONS

There is a correlation between CACS and cardiac structure and function in non-dialysis CKD patients, which may mainly involve abnormalities in left ventricular structure and cardiac diastolic function. CAC may affect renal prognosis and quality of survival in CKD patients. Based on clinical information, HF, valvular calcification status and indicators related to left ventricular hypertrophy can identify people at risk for severe CAC.

Bone mineral density and the risk of kidney disease in patients with type 1 diabetes

AIM

To explore the association between bone disorder and the risk for progression of diabetic kidney disease (DKD) in persons with type 1 diabetes mellitus (T1DM).

METHODS

In this prospective cohort study the association between bone mineral density (BMD), bone-derived factors (sclerostin, Dickkopf-1, and osteoprotegerin (OPG)), and four outcomes were investigated: 1) progression of albuminuria; 2) decline in estimated glomerular filtration rate (eGFR) ≥30 %; 3) kidney failure (KF); and 4) a composite kidney outcome consisting of at least one of the outcomes.

RESULTS

In 318 participants (median follow-up time 5.5 years) patients with osteoporosis (BMD with T-score < -2.5) had increased risk of eGFR decline: hazard ratio (HR) 2.56 (95 % CI 1.06-6.19, p = 0.04), KF: HR 9.92 (95 % CI 1.16-84.95, p = 0.04), and the composite kidney outcome: HR 2.42 (95 % CI 1.18-4.96, p = 0.02). Patients with high OPG had increased risk of eGFR decline, KF, and the composite outcome, compared to patients with low OPG in unadjusted analysis. No bone-derived factor was associated with any outcome in adjusted analyses.

CONCLUSIONS

In patients with T1DM low BMD was associated with progression of DKD, suggesting an interaction between bone and kidney.

Histone deacetylase 9 promotes osteogenic trans-differentiation of vascular smooth muscle cells via ferroptosis in chronic kidney disease vascular calcification

Vascular calcification, a common complication of chronic kidney disease (CKD), remains an unmet therapeutic challenge. The trans-differentiation of vascular smooth muscle cells (VSMCs) into osteoblast-like cells is crucial in the pathogenesis of vascular calcification in CKD. Despite ferroptosis promotes vascular calcification in CKD, the upstream or downstream regulatory mechanisms involved remains unclear. In this study, we aimed to investigate the regulatory mechanism involved in ferroptosis in CKD vascular calcification. Transcriptome sequencing revealed a potential relationship between HDAC9 and ferroptosis in CKD vascular calcification. Subsequently, we observed increased expression of HDAC9 in calcified arteries of patients undergoing hemodialysis and in a rat model of CKD. We further demonstrated that knockout of HDAC9 attenuates osteogenic trans-differentiation and ferroptosis in VSMCs stimulated by high calcium and phosphorus. In addition, RSL3 exacerbated ferroptosis and osteogenic trans-differentiation of VSMCs exposed to high levels of calcium and phosphorus, and these effects were suppressed to some extent by HDAC9 knockout. In summary, our findings suggest that HDAC9 promotes VSMCs osteogenic trans-differentiation involving ferroptosis, providing new insights for the therapy of CKD vascular calcification.

The Agatston score is a predictor of contrast-induced nephropathy in patients with stable coronary artery disease after percutaneous coronary intervention

Introduction

Agatston coronary artery calcium (CAC) scoring is the primary scoring method used to determine the summed value of calcium burden. The Agatston CAC score method is a non-invasive, rapid, easily accessible tool that helps identify the weighted sum of the calcium burden in arteries using multi-detector computed tomography. The Agatston CAC score is a significant prognostic indicator for vascular diseases in the long term.

Aim

To investigate the relationship between the Agatston CAC score and contrast-induced acute kidney injury (C-AKI) in patients with stable coronary artery disease (CAD) following a percutaneous coronary intervention (PCI).

Material and methods

This retrospective study included 360 patients with stable CAD who received PCI between January 2023 and December 2023. The Agatston score was measured non-invasively on computed tomography before the coronary angiography. Receiver operating characteristics (ROC) curve analysis was used to determine the sensitivity and specificity of the Agatston CAC score and the optimal cutoff value for predicting C-AKI.

Results

The 360 patients included in the study were divided into two groups. 71 patients were classified as C-AKI+ while 289 patients were classified as C-AKI-. There was no significant difference in terms of gender, but the C-AKI+ group was significantly older. The C-AKI+ group was observed to have significantly higher levels of uric acid, Agatston score and Mehran score. Regression analyses showed that age, uric acid, Agatston score and Mehran score were independent risk factors for C-AKI.

Conclusions

The Agatston CAC score was found to be an independent risk factor for C-AKI in patients with stable CAD with PCI.

Association of serum HIF-1α levels with coronary artery calcification in patients of non-dialysis chronic kidney disease

Vascular calcification is the main cause of death in patients with chronic kidney disease (CKD). The study aims to investigate the risk factor affecting coronary artery calcification (CAC), and the relationship between serum hypoxia-inducible factor-1α (HIF-1α) levels and CAC in non-dialysis CKD patients. One hundred and twenty-three patients were selected in the final analysis. Spearman rank correlation analysis assessed the correlation between HIF-1α levels and CAC scores. Logistic regression analysis was utilized to assess potential risk variables associated with CAC. A ROC curve was drawn to analyze the diagnostic value of HIF-1α in non-dialysis CKD patients with CAC. Compared to the non-CAC group, the CAC group was older age, with a higher proportion of males, smokers, hypertension and diabetes, lower eGFR and HDL-C, and higher SBP and HIF-1α levels. As the HIF-1α levels went up, the proportion of patients with VC increased, as well as Agatston scores. Spearman rank correlation analysis showed that HIF-1α levels were positively correlated with VC and Agatston scores. Logistic regression analysis indicated that being male (OR = 0.242, P = 0.036), older age (OR = 1.093, P < 0.001), and increased HIF-1α levels (OR = 1.002, P = 0.025) were risk factors for the occurrence of CAC. Furthermore, ROC curve analysis determined that a HIF-1α cutoff value of 451.177 pg·mL-1 provided the best diagnostic value for non-dialysis CAC, with a sensitivity of 65.8% and a specificity of 80.9%. The prevalence of CAC is high in non-dialysis CKD patients, with old age and male gender being traditional risk factors for CAC occurrence. HIF-1α positively correlate with both CAC and VC, which can provide certain diagnostic values for non-dialysis CAC.

Association between progression of coronary artery calcification and development of kidney failure with replacement therapy: Findings from KNOW-CKD study

BACKGROUND AND AIMS

High coronary artery calcification (CAC) burden is a significant risk factor for adverse cardiovascular and kidney outcomes. However, it is unknown whether changes in the coronary atherosclerotic burden can accompany changes in kidney disease progression. Here, we evaluated the relationship between CAC progression and the risk of kidney failure with replacement therapy (KFRT).

METHODS

We analyzed 1173 participants with chronic kidney disease (CKD) G1 to G5 without kidney replacement therapy from the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD). Participants were categorized into three groups according to the change in the CAC score between enrollment and year 4 (non-progressors, ≤0 AU; moderate progressors, 1-199 AU; and severe progressors, ≥200 AU). The primary outcome was the development of KFRT.

RESULTS

During a follow-up period of 4690 person-years (median, 4.2 years), the primary outcome occurred in 230 (19.6 %) participants. The incidence of KFRT was 37.6, 54.3, and 80.9 per 1000 person-years in the non-, moderate, and severe progressors, respectively. In the multivariable cause-specific hazard model, the hazard ratios (HRs) for the moderate and severe progressors were 1.71 (95 % confidence interval [CI], 1.02-2.87) and 2.55 (95 % CI, 1.07-6.06), respectively, compared with non-progressors. A different definition of CAC progression with a threshold of 100 AU yielded similar results in a sensitivity analysis.

CONCLUSIONS

CAC progression is associated with an increased risk of KFRT in patients with CKD. Our findings suggest that coronary atherosclerosis changes increase the risk of CKD progression.

Impact of Arterial Calcification on Cardiovascular and Renal Outcomes in Kidney Transplant Patients

Introduction

Coronary artery calcification score (CACS) and abdominal aortic calcification score (AACS) are both well-established markers of vascular stiffness, and previous studies have shown that a higher CACS is a risk factor for chronic kidney disease (CKD) progression. However, the impact of pretransplant CACS and AACS on cardiovascular and renal outcomes in kidney transplant patients has not been established.

Methods

We included 944 kidney transplant recipients from the KoreaN cohort study for Outcome in patients With Kidney Transplantation (KNOW-KT) cohort and categorized them into three groups (low, medium, and high) according to baseline CACS (0, 0 < and ≤100, >100) and AACS (0, 1-4, >4). The low (0), medium (0 < and ≤ 100), and high (>100) CACS groups each consisted of 462, 213, and 225 patients, respectively. Similarly, the low (0), medium (1-4), and high (>4) AACS groups included 638, 159, and 147 patients, respectively. The primary outcome was the occurrence of cardiovascular events. The secondary outcomes were all-cause mortality and composite kidney outcomes, which comprised of >50% decline in the estimated glomerular filtration rate and graft loss. Cox regression analysis was used to investigate the association between baseline CACS/AACS and outcomes.

Results

The high CACS group (N = 462) faced a significantly higher risk for cardiovascular outcomes (adjusted hazard ratio [aHR], 5.97; 95% confidence interval [CI], 2.01-17.7) and all-cause mortality (aHR, 2.74; 95% CI, 1.27-5.92) compared to the low CACS group (N = 225). Similarly, the high AACS group (N = 638) had an elevated risk for cardiovascular outcomes (aHR, 2.38; 95% CI, 1.16-4.88). Furthermore, the addition of CACS to prediction models improved prediction indices for cardiovascular outcomes. However, the risk of renal outcomes did not differ among CACS or AACS groups.

Conclusion

Pretransplant arterial calcification, characterized by high CACS or AACS, is an independent risk factor for cardiovascular outcomes and mortality in kidney transplant patients.

Triglyceride-glucose index is an independent predictor of coronary artery calcification progression in patients with chronic kidney disease

BACKGROUND

Coronary artery calcification (CAC) is highly prevalent in patients with chronic kidney disease (CKD) and is associated with major adverse cardiovascular events and metabolic disturbances. The triglyceride-glucose index (TyGI), a novel surrogate marker of metabolic syndrome and insulin resistance, is associated with CAC in the general population and in patients with diabetes. This study investigated the association between the TyGI and CAC progression in patients with CKD, which is unknown.

METHODS

A total of 1,154 patients with CKD (grades 1-5; age, 52.8 ± 11.9 years; male, 688 [59.6%]) were enrolled from the KNOWCKD (KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease). The TyGI was calculated as follows: ln (fasting triglycerides × fasting glucose/2). Patients were classified into tertiles (low, intermediate, high) based on the TyGI. The primary outcome was annualized percentage change in CAC score [(percent change in CAC score + 1)12/follow-up months - 1] of ≥15%, defined as CAC progression.

RESULTS

During the 4-year follow-up, the percentage of patients with CAC progression increased across TyGI groups (28.6%, 37.5%, and 46.2% in low, intermediate, and high groups, respectively; p < 0.001). A high TyGI was associated with an increased risk of CAC progression (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.14-3.88; p = 0.02) compared to the low group. Moreover, a 1-point increase in the TyGI was related to increased risk of CAC progression (OR, 1.55; 95% CI, 1.06-1.76; p = 0.02) after adjustment.

CONCLUSION

A high TyGI may be a useful predictor of CAC progression in CKD.

Association between the neutrophil-to-lymphocyte ratio and in-hospital mortality in patients with chronic kidney disease and coronary artery disease in the intensive care unit

BACKGROUND

The objective of this study was to investigate the correlation between neutrophil-to-lymphocyte ratios (NLR) and the risk of in-hospital death in patients admitted to the intensive care unit (ICU) with both chronic kidney disease (CKD) and coronary artery disease (CAD).

METHODS

Data from the MIMIC-IV database, which includes a vast collection of more than 50,000 ICU admissions occurring between 2008 and 2019, was utilized in the study and eICU-CRD was conducted for external verification. The Boruta algorithm was employed for feature selection. Univariable and multivariable logistic regression analyses and multivariate restricted cubic spline regression were employed to scrutinize the association between NLR and in-hospital mortality. The receiver operating characteristic (ROC) curves were conducted to estimate the predictive ability of NLR.

RESULTS

After carefully applying criteria to include and exclude participants, a total of 2254 patients with CKD and CAD were included in the research. The findings showed a median NLR of 7.3 (4.4, 12.1). The outcomes of multivariable logistic regression demonstrated that NLR significantly elevated the risk of in-hospital mortality (OR 2.122, 95% confidence interval [CI] 1.542-2.921, P < 0.001) after accounting for all relevant factors. Further insights from subgroup analyses unveiled that age and Sequential Organ Failure Assessment (SOFA) scores displayed an interactive effect in the correlation between NLR and in-hospital deaths. The NLR combined with traditional cardiovascular risk factors showed relatively great predictive value for in-hospital mortality (AUC 0.750).

CONCLUSION

The findings of this research indicate that the NLR can be used as an indicator for predicting the likelihood of death during a patient's stay in the intensive care unit, particularly for individuals with both CAD and CKD. The results indicate that NLR may serve as a valuable tool for assessing and managing risks in this group at high risk. Further investigation is required to authenticate these findings and investigate the mechanisms that underlie the correlation between NLR and mortality in individuals with CAD and CKD.

The Associations Between Abdominal Obesity and Coronary Artery Calcification in Chronic Kidney Disease Population

Background

Cardiovascular disease (CVD) is the primary cause of mortality in chronic kidney disease (CKD) patients, with metabolic disorders exacerbating this risk. Compared with body mass index, waist circumference (WC) has been proposed as a more effective indicator of abnormal visceral fat. However, the associations among CKD, abnormal WC, and CVD remain understudied.

Material and Methods

A cross-sectional study in Taiwan (July 2006 to May 2016) involved 10,342 participants undergoing self-paid health checkups at a single medical center. Physical examinations and blood samples were taken to assess metabolic parameters, and renal function was evaluated using the Chronic Kidney Disease Epidemiology Collaboration formula. Coronary artery calcification (CAC) scores were determined through coronary 256-slice multidetector computed tomography angiography, with a CAC score of >0 Agatston unit (AU) and ≥ 400 AU denoting positive CAC and severe CAC, respectively.

Results

Sex-based comparisons were conducted between individuals with CKD and those without CKD. In the CKD group, both sexes exhibited significantly elevated levels for systolic blood pressure, serum fasting blood glucose (FBG), and hemoglobin A1c (HbA1c) as well as reduced serum high-density lipoprotein cholesterol. Examination of the associations of abnormal WC revealed that for both sexes, individuals with abdominal obesity (AO) were significantly older and had higher systolic/diastolic blood pressure, serum FBG, HbA1c, and lipid profiles compared with those without AO. Multiple logistic regression analysis revealed that CKD patients exhibited a more pronounced association with severe CAC scores compared with AO patients (odds ratios [ORs]: 2.7 and 1.4, respectively). Furthermore, the combined effects of AO and CKD (AO[+]/CKD[+]) resulted in increased risks of positive CAC (OR: 2.4, 95% confidence interval [CI]: 1.6-3.5) and severe CAC (OR: 4.4, 95% CI: 1.4-14.2).

Conclusion

Abdominal obesity significantly raised the odds of CAC and was associated to a 4.4-fold increased risk of severe CAC in CKD patients.

Association of Serum Activin Levels with Allograft Outcomes in Patients with Kidney Transplant: Results from the KNOW-KT

INTRODUCTION

Serum activin A has been reported to contribute to vascular calcification and kidney fibrosis in chronic kidney disease. We aimed to investigate whether higher serum activin levels were associated with poor allograft outcomes in patients with kidney transplantation (KT).

METHODS

A total of 860 KT patients from KNOW-KT (Korean Cohort Study for Outcome in Patients with Kidney Transplantation) were analyzed. We measured serum activin levels pre-KT and 1 year after KT. The primary outcome was the composite of a ≥50% decline in estimated glomerular filtration rate and graft failure. Multivariable cause-specific hazard model was used to analyze association of 1-year activin levels with the primary outcome. The secondary outcome was coronary artery calcification score (CACS) at 5 years after KT.

RESULTS

During the median follow-up of 6.7 years, the primary outcome occurred in 109 (12.7%) patients. The serum activin levels at 1 year were significantly lower than those at pre-KT (488.2 ± 247.3 vs. 704.0 ± 349.6). When patients were grouped based on the median activin level at 1 year, the high-activin group had a 1.91-fold higher risk (95% CI, 1.25-2.91) for the primary outcome compared to the low-activin group. A one-standard deviation increase in activin levels as a continuous variable was associated with a 1.36-fold higher risk (95% CI, 1.16-1.60) for the primary outcome. Moreover, high activin levels were significantly associated with 1.56-fold higher CACS (95% CI, 1.12-2.18).

CONCLUSION

Post-transplant activin levels were independently associated with allograft functions as well as coronary artery calcification in KT patients.

Inflammation and gut dysbiosis as drivers of CKD-MBD

Two decades ago, Kidney Disease: Improving Global Outcomes coined the term chronic kidney disease-mineral and bone disorder (CKD-MBD) to describe the syndrome of biochemical, bone and extra-skeletal calcification abnormalities that occur in patients with CKD. CKD-MBD is a prevalent complication and contributes to the excessively high burden of fractures and cardiovascular disease, loss of quality of life and premature mortality in patients with CKD. Thus far, therapy has focused primarily on phosphate retention, abnormal vitamin D metabolism and parathyroid hormone disturbances, but these strategies have largely proved unsuccessful, thus calling for paradigm-shifting concepts and innovative therapeutic approaches. Interorgan crosstalk is increasingly acknowledged to have an important role in health and disease. Accordingly, mounting evidence suggests a role for both the immune system and the gut microbiome in bone and vascular biology. Gut dysbiosis, compromised gut epithelial barrier and immune cell dysfunction are prominent features of the uraemic milieu. These alterations might contribute to the inflammatory state observed in CKD and could have a central role in the pathogenesis of CKD-MBD. The emerging fields of osteoimmunology and osteomicrobiology add another level of complexity to the pathogenesis of CKD-MBD, but also create novel therapeutic opportunities.

Is coronary artery calcium an independent risk factor for white matter hyperintensity?

BACKGROUND

Cardiovascular diseases have been considered the primary cause of disability and death worldwide. Coronary artery calcium (CAC) is an important indicator of the severity of coronary atherosclerosis. This study is aimed to investigate the relationship between CAC and white matter hyperintensity (WMH) in the context of diagnostic utility.

METHODS

A retrospective analysis was conducted on 342 patients with a diagnosis of WMH on magnetic resonance images (MRI) who also underwent chest computed tomography (CT) scans. WMH volumes were automatically measured using a lesion prediction algorithm. Subjects were divided into four groups based on the CAC score obtained from chest CT scans. A multilevel mixed-effects linear regression model considering conventional vascular risk factors assessed the association between total WMH volume and CAC score.

RESULTS

Overall, participants with coronary artery calcium (CAC score > 0) had larger WMH volumes than those without calcium (CAC score = 0), and WMH volumes were statistically different between the four CAC score groups, with increasing CAC scores, the volume of WMH significantly increased. In the linear regression model 1 of the high CAC score group, for every 1% increase in CAC score, the WMH volume increases by 2.96%. After including other covariates in model 2 and model 3, the β coefficient in the high CAC group remains higher than in the low and medium CAC score groups.

CONCLUSION

In elderly adults, the presence and severity of CAC is related to an increase in WMH volume. Our findings suggest an association between two different vascular bed diseases in addition to traditional vascular risk factors, possibly indicating a comorbid mechanism.

Effects of Finerenone on Cardiovascular and Chronic Kidney Diseases: A New Weapon against Cardiorenal Morbidity and Mortality-A Comprehensive Review

Patients with cardiovascular disease (CVD) and chronic kidney disease (CKD) show high rates of cardiorenal outcomes. In addition, the progression towards renal failure and cardiovascular events rises as CKD worsens. Several studies suggest that the activation of the mineralocorticoid receptor (MR) induces cardiac and renal injury, including inflammation and fibrosis. Finerenone is a novel, nonsteroidal, selective MR antagonist (MRA) which has demonstrated anti-inflammatory and anti-fibrotic effects in pre-clinical studies. Moreover, two large trials (FIDELIO-DKD and FIGARO-DKD) investigated the renal and cardiovascular outcomes in patients with mild to severe CKD in type 2 diabetes which received finerenone. On these bases, this comprehensive review aims to summarize the current knowledge regarding finerenone and its effects on CKD and the cardiovascular system, emphasizing its role in modifying cardiorenal outcomes.

Pathophysiology and Clinical Impacts of Chronic Kidney Disease on Coronary Artery Calcification

The global prevalence of chronic kidney disease (CKD) has increased in recent years. Adverse cardiovascular events have become the main cause of life-threatening events in patients with CKD, and vascular calcification is a risk factor for cardiovascular disease. Vascular calcification, especially coronary artery calcification, is more prevalent, severe, rapidly progressive, and harmful in patients with CKD. Some features and risk factors are unique to vascular calcification in patients with CKD; the formation of vascular calcification is not only influenced by the phenotypic transformation of vascular smooth muscle cells, but also by electrolyte and endocrine dysfunction, uremic toxin accumulation, and other novel factors. The study on the mechanism of vascular calcification in patients with renal insufficiency can provide a basis and new target for the prevention and treatment of this disease. This review aims to illustrate the impact of CKD on vascular calcification and to discuss the recent research data on the pathogenesis and factors involved in vascular calcification, mainly focusing on coronary artery calcification, in patients with CKD.

Progression of Vascular Calcification and Clinical Outcomes in Patients Receiving Maintenance Dialysis

Importance

Baseline findings from the China Dialysis Calcification Study (CDCS) revealed a high prevalence of vascular calcification (VC) among patients with end-stage kidney disease; however, data on VC progression were limited.

Objectives

To understand the progression of VC at different anatomical sites, identify risk factors for VC progression, and assess the association of VC progression with the risk of cardiovascular events and death among patients receiving maintenance dialysis.

Design, Setting, and Participants

This cohort study was a 4-year follow-up assessment of participants in the CDCS, a nationwide multicenter prospective cohort study involving patients aged 18 to 74 years who were undergoing hemodialysis or peritoneal dialysis. Participants were recruited from 24 centers across China between May 1, 2014, and April 30, 2015, and followed up for 4 years. A total of 1489 patients receiving maintenance dialysis were included in the current analysis. Data were analyzed from September 1 to December 31, 2021.

Exposures

Patient demographic characteristics and medical history; high-sensitivity C-reactive protein laboratory values; serum calcium, phosphorus, and intact parathyroid hormone (iPTH) values; and previous or concomitant use of medications.

Main Outcomes and Measures

The primary outcome was progression of VC at 3 different anatomical sites (coronary artery, abdominal aorta, and cardiac valves) and identification of risk factors for VC progression. Participants received assessments of coronary artery calcification (CAC), abdominal aortic calcification (AAC), and cardiac valve calcification (CVC) at baseline, 24 months, 36 months, and 48 months. Secondary outcomes included (1) the association between VC progression and the risk of all-cause death, cardiovascular (CV)-related death, and a composite of all-cause death and nonfatal CV events and (2) the association between achievement of serum calcium, phosphorus, and iPTH target levels and the risk of VC progression.

Results

Among 1489 patients, the median (IQR) age was 51.0 (41.0-60.0) years; 59.5% of patients were male. By the end of 4-year follow-up, progression of total VC was observed in 86.5% of patients; 69.6% of patients had CAC progression, 72.4% had AAC progression, and 33.4% had CVC progression. Common risk factors for VC progression at the 3 different anatomical sites were older age and higher fibroblast growth factor 23 levels. Progression of CAC was associated with a higher risk of all-cause death (model 1 [adjusted for age, sex, and body mass index]: hazard ratio [HR], 1.97 [95% CI, 1.16-3.33]; model 2 [adjusted for all factors in model 1 plus smoking status, history of diabetes, and mean arterial pressure]: HR, 1.89 [95% CI, 1.11-3.21]; model 3 [adjusted for all factors in model 2 plus calcium, phosphorus, intact parathyroid hormone, and fibroblast growth factor 23 levels and calcium-based phosphate binder use]: HR, 1.92 [95% CI, 1.11-3.31]) and the composite of all-cause death and nonfatal CV events (model 1: HR, 1.98 [95% CI, 1.19-3.31]; model 2: HR, 1.91 [95% CI, 1.14-3.21]; model 3: HR, 1.95 [95% CI, 1.14-3.33]) after adjusting for all confounding factors except the presence of baseline calcification. Among the 3 targets of calcium, phosphorus, and iPTH, patients who achieved no target levels (model 1: odds ratio [OR], 4.75 [95% CI, 2.65-8.52]; model 2: OR, 4.81 [95% CI, 2.67-8.66]; model 3 [for this analysis, adjusted for all factors in model 2 plus fibroblast growth factor 23 level and calcium-based phosphate binder use]: OR, 2.76 [95% CI, 1.48-5.16]), 1 target level (model 1: OR, 3.71 [95% CI, 2.35-5.88]; model 2: OR, 3.62 [95% CI, 2.26-5.78]; model 3: OR, 2.19 [95% CI, 1.33-3.61]), or 2 target levels (model 1: OR, 2.73 [95% CI, 1.74-4.26]; model 2: OR, 2.69 [95% CI, 1.71-4.25]; model 3: OR, 1.72 [95% CI, 1.06-2.79]) had higher odds of CAC progression compared with patients who achieved all 3 target levels.

Conclusions and Relevance

In this study, VC progressed rapidly in patients undergoing dialysis, with different VC types associated with different rates of prevalence and progression. Consistent achievement of serum calcium, phosphorus, and iPTH target levels was associated with a lower risk of CAC progression. These results may be useful for increasing patient awareness and developing appropriate strategies to improve the management of chronic kidney disease-mineral and bone disorder among patients undergoing dialysis.

Cardiovascular Calcification Heterogeneity in Chronic Kidney Disease

Patients with chronic kidney disease (CKD) exhibit tremendously elevated risk for cardiovascular disease, particularly ischemic heart disease, due to premature vascular and cardiac aging and accelerated ectopic calcification. The presence of cardiovascular calcification associates with increased risk in patients with CKD. Disturbed mineral homeostasis and diverse comorbidities in these patients drive increased systemic cardiovascular calcification in different manifestations with diverse clinical consequences, like plaque instability, vessel stiffening, and aortic stenosis. This review outlines the heterogeneity in calcification patterning, including mineral type and location and potential implications on clinical outcomes. The advent of therapeutics currently in clinical trials may reduce CKD-associated morbidity. Development of therapeutics for cardiovascular calcification begins with the premise that less mineral is better. While restoring diseased tissues to a noncalcified homeostasis remains the ultimate goal, in some cases, calcific mineral may play a protective role, such as in atherosclerotic plaques. Therefore, developing treatments for ectopic calcification may require a nuanced approach that considers individual patient risk factors. Here, we discuss the most common cardiac and vascular calcification pathologies observed in CKD, how mineral in these tissues affects function, and the potential outcomes and considerations for therapeutic strategies that seek to disrupt the nucleation and growth of mineral. Finally, we discuss future patient-specific considerations for treating cardiac and vascular calcification in patients with CKD-a population in need of anticalcification therapies.

Updates in the chronic kidney disease-mineral bone disorder show the role of osteocytic proteins, a potential mechanism of the bone-Vascular paradox, a therapeutic target, and a biomarker

The chronic kidney disease-mineral bone disorder (CKD-MBD) is a complex multi-component syndrome occurring during kidney disease and its progression. Here, we update progress in the components of the syndrome, and synthesize recent investigations, which suggest a potential mechanism of the bone-vascular paradox. The discovery that calcified arteries in chronic kidney disease inhibit bone remodeling lead to the identification of factors produced by the vasculature that inhibit the skeleton, thus providing a potential explanation for the bone-vascular paradox. Among the factors produced by calcifying arteries, sclerostin secretion is especially enlightening. Sclerostin is a potent inhibitor of bone remodeling and an osteocyte specific protein. Its production by the vasculature in chronic kidney disease identifies the key role of vascular cell osteoblastic/osteocytic transdifferentiation in vascular calcification and renal osteodystrophy. Subsequent studies showing that inhibition of sclerostin activity by a monoclonal antibody improved bone remodeling as expected, but stimulated vascular calcification, demonstrate that vascular sclerostin functions to brake the Wnt stimulation of the calcification milieu. Thus, the target of therapy in the chronic kidney disease-mineral bone disorder is not inhibition of sclerostin function, which would intensify vascular calcification. Rather, decreasing sclerostin production by decreasing the vascular osteoblastic/osteocytic transdifferentiation is the goal. This might decrease vascular calcification, decrease vascular stiffness, decrease cardiac hypertrophy, decrease sclerostin production, reduce serum sclerostin and improve skeletal remodeling. Thus, the therapeutic target of the chronic kidney disease-mineral bone disorder may be vascular osteoblastic transdifferentiation, and sclerostin levels may be a useful biomarker for the diagnosis of the chronic kidney disease-mineral bone disorder and the progress of its therapy.

Panax notoginseng Suppresses Bone Morphogenetic Protein-2 Expression in EA.hy926 Endothelial Cells by Inhibiting the Noncanonical NF-κB and Wnt/β-Catenin Signaling Pathways

Panax notoginseng (PN) exerts cardiovascular-disease-protective effects, but the effect of PN on reducing vascular calcification (VC) is unknown. Under the VC process, however, endothelial bone morphogenetic protein-2 (BMP-2) signals connect endothelial and smooth muscle cells. To investigate the effects of PN water extract (PNWE) on BMP-2 expression, human EA.hy926 endothelial cells were pretreated with PNWE for 48 h, and BMP-2 expression was then induced using warfarin/β-glycerophosphate (W/BGP) for another 24 h. The expression of BMP-2, the degrees of oxidative stress and inflammation, and the activation of noncanonical NF-κB and Wnt/β-catenin signaling were analyzed. The results showed that the BMP-2 levels in EA.hy926 cells were reduced in the groups treated with 10, 50, or 100 μg/mL PNWE combined with W/BGP. PNWE combined with W/BGP significantly reduced thiobarbituric-acid-reactive substrate and reactive oxygen species levels as well as prostaglandin E2, IL-1β, IL-6, and TNF-α. PNWE (10, 50, and 100 μg/mL) reduced the p52 levels and p52/p100 protein ratio. Wnt and β-catenin protein expression was decreased in the groups treated with PNWE combined with W/BGP. These results showed that PNWE reduced BMP-2 expression in EA.hy926 cells by inhibiting the noncanonical NF-κB and Wnt/β-catenin signaling pathways.