Abdominal aortic calcification is associated with diastolic dysfunction, mortality, and nonfatal cardiovascular events in maintenance hemodialysis patients

The Predictive Value of Aortic Calcification on Computed Tomography for Major Cardiovascular Events

As the prevalence of cardiovascular disease continues to increase, early identification of patients at high risk of major adverse cardiovascular events (MACE) using reliable diagnostic modalities is important. Transcatheter aortic valve implantation (TAVI) is a minimally invasive percutaneous procedure used to replace the aortic valve with a bioprosthetic one, often without the need for surgery. Extra coronary calcification in the ascending and/or descending thoracic aorta, aortic arch, and abdominal aorta has recently been identified as a method to quantify the extent of atherosclerotic cardiovascular disease. However, its definitive role in the prediction of MACE remains unclear. We performed a comprehensive review to summarize the current literature on the diagnostic and predictive value of thoracic and abdominal aortic calcification, as quantified in computed tomography, for the association, risk stratification, and prediction of MACE and after TAVI procedures. Despite increasing evidence, the predictive role of thoracic calcification still remains unproven, with a need for carefully tailored studies to confirm these findings.

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.

Fibroblast growth factor-23 and cardiovascular disease among prevalent hemodialysis patients focusing on residual kidney function

Background

In patients undergoing incident hemodialysis, increased fibroblast growth factor-23 (FGF-23) levels are associated with the development of cardiovascular disease (CVD), but the influence of residual kidney function (RFK) on this association is unclear. This study aimed to investigate the association between FGF-23 levels, RKF, and CVD in patients undergoing prevalent hemodialysis.

Methods

This cross-sectional and longitudinal observational study included 296 patients undergoing maintenance hemodialysis for at least three months who were followed up for a median of 44 months. RKF was defined as 24-h urine output >200 mL, left ventricular (LV) diastolic dysfunction as E/E' >15 on echocardiographic parameters. CVD was defined as hospitalization or emergency room visits due to cardiovascular causes, such as angina, myocardial infarction, or congestive heart failure.

Results

The median intact FGF-23 (iFGF-23) level was 423.8 pg/mL (interquartile range, 171-1,443). Patients with an FGF-23 level > 423.8 pg/mL significantly had a lower proportion of RKF (39.2% vs. 60.1%, P < 0.001) and a higher proportion of LV diastolic dysfunction (54. 1% vs. 29.1%, P < 0.001) than those with an iFGF-23 level ≤ 423.8 pg/mL. The odds ratio (OR) for LV diastolic dysfunction was significantly higher in patients with RFK (OR per one-unit increase in the natural log-transformed iFGF-23 levels, 1.80; 95% confidence interval [CI]: 1.11-2.93) than in patients without RKF (OR per one-unit increase in the natural log-transformed iFGF-23 levels: 1.42; 95% CI: 1.01-1.99) in multivariate analysis (p < 0.001). During the follow-up period, 55 patients experienced CVD. The hazard ratio (HR) for CVD development was also significantly higher in patients with RKF (HR per one-unit increase in the natural log-transformed iFGF-23 levels, 2.64; 95% CI: 1.29-5.40) than those without RKF (HR per one-unit increase in the natural log-transformed iFGF-23 levels: 1.44; 95% CI: 1.04-1.99) in multivariate analysis (p = 0.05).

Conclusions

Increased iFGF-23 levels were associated with LV diastolic dysfunction and CVD development in patients undergoing prevalent hemodialysis; however, the loss of RKF attenuated the magnitude of these associations. Therefore, in these patients, RKF strongly influenced the detrimental role of iFGF-23 in the development of CVD.

Cardiac valve calcification in patients on maintenance dialysis. The role of malnutrition-inflammation syndrome, adiposity andcomponents of sarcopenia. A cross-sectional study

BACKGROUND & AIMS

Cardiac valve calcification (CVC) is a predictor of cardiovascular disease and all-cause mortality in end stage kidney disease (ESKD) patients. Several risk factors are related to CVC in patients with ESKD including traditional ones as well as inflammation, bone mineral disease and malnutrition. Adiposity is associated with dyslipidemia and proinflammatory activity which could predispose for CVC. Sarcopenia or dynapenia is a state common in patients with ESKD. This study aimed to investigate the relationship of adiposity, sarcopenia and malnutrition-inflammation markers with CVC in patients on maintenance hemodialysis.

METHODS

CVC in aortic (AVC), mitral valves (MVC) and systolic and diastolic dysfunction (DD) were assessed by using two-dimensional echocardiography. Nutritional, adiposity and anthropometric assessments were made using several indices respectively. Creatinine index and muscle strength measurements were also performed. Biochemical parameters such as total proteins, albumin, calcium, phosphate, plasma lipoproteins, C-Reactive Protein and parathyroid hormone were also measured.

RESULTS

Adiposity, nutritional, and sarcopenia parameters did not show any difference between patients with or without CVC. Age ≥ 65 years [PR: 1.47 p = 0.012], DD [PR: 2.31, p = 0.005], high CRP/albumin ratio [PR: 1.46, p = 0.01], mid arm circumference (MAC) < 26 cm [PR: 1.37, p = 0.03] were associated with increased prevalence of AVC, while DD [PR: 1.97 p = 0.02], high CRP/albumin ratio [PR: 1.56, p = 0.02], and MAC < 26 cm [PR: 1.52, p = 0.01], showed positive correlation with MVC. Age ≥ 65 years [PR: 1.33, p = 0.028], DD [PR: 1.72, p = 0.01], high CRP/albumin ratio [PR: 1.53, p = 0.003], and MAC < 26 cm [PR: 1.4, p = 0.006], related to greater prevalence of calcification at any valve.

CONCLUSIONS

Ageing, diastolic dysfunction, MAC and increased CRP/albumin ratio were powerful predictors of CVC in patients on hemodialysis.

The combined clinical impact of red blood cell distribution width and vascular calcification on cardiovascular events and mortality in patients with end-stage kidney disease

Background

Little is known about how the interaction between red blood cell distribution width (RDW) and vascular calcification (VC) affects cardiovascular (CV) events and mortality in end-stage kidney disease (ESKD) patients. This study investigated the combined prognostic effect of RDW and VC in ESKD patients starting dialysis.

Methods

A retrospective single-center study of 582 ESKD patients was conducted. VC was assessed by calculating the aortic calcification index (ACI) using computed tomography. Patients were divided into low ACI-low RDW, low ACI-high RDW, high ACI-low RDW, and high ACI-high RDW groups based on median ACI (17.12) and RDW (14.3) values. The association between RDW and VC and the composite endpoint of CV events and death was analyzed.

Results

During a median follow-up of 3.1 years (range, 1.5–5.5 years), 165 CV events (28.4%) and 124 deaths (21.4%) occurred. Cox regression showed that the low ACI-high RDW (adjusted hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.04–2.66; p = 0.03) and high ACI-low RDW (adjusted HR, 1.95; 95% CI, 1.21–3.14; p = 0.006) groups had a greater risk of CV events and death than the low ACI-low RDW group. The high ACI-high RDW group had the greatest risk (adjusted HR, 2.23; 95% CI, 1.42–3.52; p = 0.001). The effect of the interaction between ACI and RDW on CV events and mortality was statistically significant (p = 0.005).

Conclusion

High RDW and VC interact to increase the risk of CV events and death in ESKD patients.

Prognostic Value of Abdominal Aortic Calcification: A Systematic Review and Meta-Analysis of Observational Studies

Background The prognostic importance of abdominal aortic calcification (AAC) viewed on noninvasive imaging modalities remains uncertain. Methods and Results We searched electronic databases (MEDLINE and Embase) until March 2018. Multiple reviewers identified prospective studies reporting AAC and incident cardiovascular events or all-cause mortality. Two independent reviewers assessed eligibility and risk of bias and extracted data. Summary risk ratios (RRs) were estimated using random-effects models comparing the higher AAC groups combined (any or more advanced AAC) to the lowest reported AAC group. We identified 52 studies (46 cohorts, 36 092 participants); only studies of patients with chronic kidney disease (57%) and the general older-elderly (median, 68 years; range, 60-80 years) populations (26%) had sufficient data to meta-analyze. People with any or more advanced AAC had higher risk of cardiovascular events (RR, 1.83; 95% CI, 1.40-2.39), fatal cardiovascular events (RR, 1.85; 95% CI, 1.44-2.39), and all-cause mortality (RR, 1.98; 95% CI, 1.55-2.53). Patients with chronic kidney disease with any or more advanced AAC had a higher risk of cardiovascular events (RR, 3.47; 95% CI, 2.21-5.45), fatal cardiovascular events (RR, 3.68; 95% CI, 2.32-5.84), and all-cause mortality (RR, 2.40; 95% CI, 1.95-2.97). Conclusions Higher-risk populations, such as the elderly and those with chronic kidney disease with AAC have substantially greater risk of future cardiovascular events and poorer prognosis. Providing information on AAC may help clinicians understand and manage patients' cardiovascular risk better.

The combined prognostic significance of alkaline phosphatase and vascular calcification in patients with end-stage kidney disease

BACKGROUND AND AIMS

Little is known about the interaction between serum alkaline phosphatase (ALP) and vascular calcification (VC) affecting cardiovascular events (CVE) and mortality in end-stage kidney disease (ESKD) patients. This study investigated the combined effect of ALP and VC on prognosis in ESKD patients starting dialysis.

METHODS AND RESULTS

Data from 587 ESKD patients treated at a single center between January 2006 and July 2017 were retrospectively evaluated. VC was assessed by the aortic calcification index (ACI) using abdominal computed tomography. Patients were stratified into four groups according to the median ACI (17.18) and serum ALP value (108.0 U/L) as low ACI-low ALP, low ACI-high ALP, high ACI-low ALP, or high ACI-high ALP. The association between ALP and VC and the composite of CVE and death was analyzed. During a median follow-up of 3.1 years (range, 1.5-5.6 years), 140 patients (23.8%) developed CVE and 130 deaths (22.1%) occurred. In the stratified analysis, patients with high ACI-low ALP had a greater risk of the composite endpoint than patients with low ACI-low ALP (adjusted hazard ratio, 2.09; 95% confidence interval, 1.58-2.60; P = 0.004). Patients with high ACI-high ALP had the greatest risk (adjusted hazard ratio, 2.25; 95% confidence interval, 1.77-2.72; P = 0.001). The interaction between ACI and ALP on CVE and mortality was statistically significant (P < 0.05).

CONCLUSIONS

The combined effect of VC and higher ALP was associated with a greater risk of CVE and death, and high serum ALP amplified the risk associated with VC in ESKD patients starting dialysis.

Abdominal aortic calcification score predicts the occurrence of coronary artery disease in middle-aged peritoneal dialysis patients

AIM

Abdominal aortic calcification (AAC) score in dialysis patients was associated with coronary artery disease (CAD) in cross-sectional study, but the use of AAC score in the CAD prediction was not clear. We aimed to use AAC score in the estimation of CAD occurrence in middle-aged peritoneal dialysis (PD) patients.

METHODS

Middle-aged (45-65 years old) PD patients were recruited and followed up until CAD occurrence, patient mortality, or PD failure. We quantified AAC score by lateral lumbar radiography, and used receiver operation curve (ROC) analysis to find the cut-off value for CAD prediction.

RESULTS

There were 187 patients recruited for study with a mean follow-up of 1027 ± 427 days. AAC score in patients with CAD during follow-up period (9.7 ± 7.6, n = 41) was higher than in patients without CAD occurrence (5.5 ± 6.1, n = 146) (P < 0.001). Multivariate hazard ratio of AAC score for CAD was 1.07 (P = 0.044). ROC showed that AAC score of 5.5 had a sensitivity of 0.667 and a specificity of 0.581 in the prediction of CAD occurrence. Patients with AAC score above 5.5 had significantly higher cumulative incidence of CAD than patients with AAC score below 5.5 (Log-rank test, P = 0.003). Age (P = 0.002), diabetes (P = 0.002), hypertension (P = 0.032), longer dialysis vintage (P < 0.001) and lower serum potassium (P = 0.012) were parameters significantly associated with higher AAC score.

CONCLUSION

AAC score can predict CAD occurrence in PD patients. Age, diabetes, hypertension, dialysis vintage and serum potassium level are factors associated with higher AAC score.

Tissue Doppler imaging predicts outcomes in hemodialysis patients with preserved left ventricular function

BACKGROUND

Cardiovascular disease is a major cause of mortality in patients with end-stage renal disease (ESRD). In addition to arteriosclerosis (arterial stiffness) and atherosclerosis, left ventricular (LV) hypertrophy and LV systolic dysfunction are the major cardiac determinants of cardiovascular mortality in hemodialysis patients. Although LV diastolic dysfunction is common in patients with ESRD, its prognostic value is yet to be established.

METHODS

A total of 103 ESRD patients (52 females, 51 males, age 51 ± 14 years) receiving regular hemodialysis and with preserved LV systolic function were prospectively enrolled in the current study. A comprehensive cardiovascular evaluation was performed at baseline. LV diastolic function was assessed using Doppler mitral inflow velocity and tissue Doppler imaging (TDI) of the mitral annulus velocity. Predictors for hospitalization and all-cause mortality were identified via Cox proportional hazards analysis.

RESULTS

There were 20 deaths and 46 hospitalizations during a follow-up period of 67.9 ± 20.2 months. After adjusting for age, aortic pulse wave velocity (PWV), and carotid intima media thickness, Cox analysis demonstrated that ratio of early ventricular filling velocity (E) to early diastolic tissue velocity mitral annulus (E') (E/E') was a significant predictor for hospitalization (hazard ratio [HR] 1.235 and 95% CI 1.115-1.368 per-1SD). E' also independently predicted mortality (HR 0.682, 95% CI 0.472-0.985). The TDI parameters significantly correlated with the LV mass index and PWV.

CONCLUSION

The findings of the current study suggest that diastolic function, as indexed by TDI, is an independent predictor of hospitalization and mortality in ESRD patients receiving regular hemodialysis and with preserved LV systolic function. The TDI parameters may reflect the impairment of arterial function and LV pressure overload.

Abdominal aortic calcification can predict all-cause mortality and CV events in dialysis patients: A systematic review and meta-analysis

BACKGROUND

Abdominal aortic calcification (AAC) has a pretty high incidence in dialysis patients and may be associated with their prognosis. AAC can be assessed by abdominal CT or X-ray. We determined to investigate whether the occurrence of AAC is associated with all-cause mortality and cardiovascular (CV) events in dialysis patients through this meta-analysis and systematic review.

METHODS

A comprehensive literature search was conducted using the PubMed, Cochrane library, Embase, Medline databases to collect cohort studies investigating whether AAC is associated with all-cause mortality and CV events of patients, and we also searched gray articles and conferences abstracts. Meta-analysis was performed by STATA software. Pooled results were expressed as hazard ratio (HR) with corresponding 95% confidence intervals (CI). Fixed-effect models were used to pool the HR of each trial.

RESULTS

10 studies (2,724 dialysis patients) were identified. The presence of AAC was associated with increased risk for all-cause mortality among dialysis patients (HR, 2.84; 95% CI, 2.03-3.98; I2 = 9.8%; P = 0.354). Meanwhile, there was an association between AAC and increased risk for all CV events (fatal and non-fatal) in patients (HR, 2.04; 95% CI, 1.51-2.76, I2 = 44.6%; P = 0.125). 3 studies presented their endpoint as CV mortality, and the pooled HR was 2.46 (95%CI 1.38-4.40; I2 = 0.0%; P = 0.952). There were also 2 studies that reported their primary endpoint as all-cause mortality and CV events, and the pooled HR was 5.72 (95% CI 3.24-10.10; I2 = 0.0%; P = 0.453).

CONCLUSIONS

Among patients treated with dialysis, AAC is associated with adverse outcomes, including all-cause mortality and CV events (fatal and non-fatal). The abdominal X-ray or CT scan can be used as a useful added method to evaluate the patient's calcification. This may provide reasonable data for estimating the risk of adverse events in dialysis patients, which is helpful in guiding clinical treatment and improving the prognosis of dialysis patients.

Prognostic value of cardiovascular calcifications in hemodialysis patients: a longitudinal study

PURPOSE

Cardiovascular calcifications (CVC) are present in up to 70% of non-diabetic dialysis patients. Sparse data are available on predictors of very long-term outcomes of such patients. The Belgrade Aachen Study on Calcification in Hemodialysis patients (BASCH study) aimed to study this using a comprehensive CVC assessment.

METHODS

We prospectively analyzed 220 hemodialysis patients followed for a mean of 76 months (median 73 months, range 6-160 months). We compared patients deceased from cardiovascular diseases (CVD) and survivors. Analyses included composite calcification scores (determined by combining ultrasound and X-ray analyses), demographic, clinical and laboratory data and pulse wave velocity (PWV). For survival analysis, patients were divided into group according to quartiles (Q).

RESULTS

Compared to survivors, deceased patients from CVD were significantly older, more frequently hypertensive, had shorter dialysis times per week and lower Kt/V values, and they exhibited lower serum fetuin A, osteoprotegerin and hemoglobin as well as higher CRP levels. Composite calcification and Adragao scores were significantly higher in deceased patients from CVD as was PWV. Mean survival was 101 ± 47 months (Q1), 87 ± 51 month (Q2), 66 ± 48 (Q3) and 54 ± 45 months (Q4), p = 0.000. Cox multivariate regression analysis showed that independent predictors for cardiovascular mortality were composite calcification score in the range of third and fourth quartiles.

CONCLUSION

Composite calcification score emerged as significant predictors of long-term survival in our group of largely non-diabetic dialysis patient population, finding that should be confirmed by intervention studies.

Vascular calcification and left ventricular hypertrophy in hemodialysis patients: interrelationship and clinical impacts

Background: We examined the relationship and combined effect of vascular calcification (VC) and left ventricular hypertrophy (LVH) on deaths and cardiovascular events (CVEs) in hemodialysis (HD) patients. Methods: Maintenance HD patients (n=341) were included. Echocardiography data and plain chest radiographs were used to assess LVH and aortic arch VC. Results: VC was found in 100 patients (29.3%). LVH was more prevalent in patients with VC compared with those without VC (70% vs. 50.2%, P=0.001). VC was independently associated with a 2.42-fold increased risk of LVH (95% CI, 1.26-4.65). In multivariate analysis, compared with patients with neither VC nor LVH, the coexistence of VC and LVH was independently associated with CVE (HR, 2.01; 95% CI, 1.09-3.72), whereas VC or LVH alone was not. Patients with both VC and LVH had the highest risk for a composite event of deaths or CVE (HR, 1.88; 95% CI, 1.15-3.06). Significant synergistic interaction was observed between VC and LVH (P for interaction=0.039). Conclusions: VC was independently associated with LVH. The coexistence of VC and LVH was associated with higher risk of deaths and CVEs than either factor alone. VC and LVH showed a synergistic interaction for the risk of deaths and CVEs.

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.

High Serum Phosphorus Level Is Associated with Left Ventricular Diastolic Dysfunction in Peritoneal Dialysis Patients

Objectives

We initiated this study to explore the relationships of serum phosphorus level with left ventricular ultrasound features and diastolic function in peritoneal dialysis (PD) patients.

Methods

174 patients with end-stage renal disease (ESRD) receiving PD were enrolled in this retrospective observational study. Conventional echocardiography examination and tissue Doppler imaging (TDI) were performed in each patient. Clinical information and laboratory data were also collected. Analyses of echocardiographic features were performed according to phosphorus quartiles groups. And multivariate regression models were used to determine the association between serum phosphorus and Left ventricular diastolic dysfunction (LVDD).

Results

With the increase of serum phosphorus levels, patients on PD showed an increased tissue Doppler-derived E/e’ ratio of lateral wall (P < 0.001), indicating a deterioration of left ventricular diastolic function. Steady growths of left atrium and left ventricular diameters as well as increase of left ventricular muscle mass were also observed across the increasing quartiles of phosphorus, while left ventricular ejection fraction remained normal. In a multivariate analysis, the regression coefficient for E/e’ ratio in the highest phosphorus quartile was almost threefold higher relative to those in the lowest quartile group. And compared with patients in the lowest phosphorus quartile (<1.34 mmol/L) those in the highest phosphorus quartile (>1.95 mmol/L) had a more than fivefold increased odds of E/e’ ratio >15.

Conclusions

Our study showed an early impairment of left ventricular diastolic function in peritoneal dialysis patients. High serum phosphorus level was independently associated with greater risk of LVDD in these patients. Whether serum phosphorus will be a useful target for prevention or improvement of LVDD remains to be proved by further studies.

Both pelvic radiography and lateral abdominal radiography correlate well with coronary artery calcification measured by computed tomography in hemodialysis patients: A cross-sectional study

Introduction Lateral abdominal radiograph is suggested as an alternative to coronary artery computed tomography (CT) in evaluating vascular calcification. Simple scoring systems including pelvic radiograph scoring and abdominal scoring system were utilized to study their correlation with coronary artery calcification. Methods In 106 MHD patients, coronary artery CT, lateral abdominal, and pelvic radiograph were taken. The Agatston scoring system was applied to evaluate the degree of coronary artery calcification which was categorized according to Agatston coronary artery calcification score (CACS) ≥ 30, ≥100, ≥400, and ≥1000. Abdominal aortic calcification was scored by 4-scored and 24-scored systems. Pelvic artery calcification was scored by a 4-scored system. Sensitivities and specificities of abdominal aortic calcification scores and pelvic artery calcification scores to predict different categories of coronary artery calcification were analyzed. We studied the diagnostic capability of abdominal aorta calcification and pelvic artery calcification to predict different CACS categories by calculating likelihood ratios. Receiver operator characteristic curves were used to determine the area under the curve for each of these testing procedures. Findings The prevalence was 48(45.3%), 15 (14.2%), 11 (10.4%), 11 (10.4%), and 11 (10.4%) for CACs > 0, ≥30, ≥100, ≥400, and ≥1000, respectively. The degree of CACs was positively correlated with patient age, prevalence of diabetes, abdominal aorta scores, and pelvic calcification scores. The areas under the curves for different CACS by all X-ray scoring systems were above 0.70 except pelvic 4-scored system for diagnosing CACS ≥30, without significant difference (P > 0.05). Discussion Both lateral abdominal and pelvic plain radiographs were demonstrated as acceptable alternatives to CT in evaluating vascular calcification.

Coronary Artery Calcification Seen Through Chest Radiography

Patients with end-stage renal disease (ESRD) on dialysis have poor overall survival, and cardiovascular (CV) is the main cause of mortality among these patients. Coronary calcification is an independent predictor of mortality and CV events in dialysis patients and can be accessed by using a computerized tomography scanning. The high cost of this procedure, however, precludes routine implementation of this method for the purposes of risk stratification. Aortic arch calcification has been associated with CV mortality in the general population. Also, vascular calcification beyond the thoracic aorta has been shown to be associated with mortality in ESRD patients. We presented here a case of a young patient with ESRD in which the coronary calcification could be cleared seen through simple chest radiography. This is a 35-year-old man with a history of ESRD secondary to pyelonephritis, who was receiving conventional hemodialysis thrice a week for the last 5 years. He was submitted to chest radiography as part of routine annual cardiac screening. His blood pressure was within the target limits, although much higher in lower limbs, generating a high ankle brachial index of 1.3. He also had secondary hyperparathyroidism. His physical examination was unremarkable, except for the presence of non-functioning arteriovenous fistulas in both arms and a central venous catheter. The last routine blood test showed calcium 9.0 mg/dL, phosphate 5.7 mg/dL, potassium 4.7 mEq/L, creatinine 7.4 mg/dL, alkaline phosphatase 175 U/L, and parathyroid hormone 1,745 pg/mL. Surprisingly, the chest radiography revealed a calcified aortic valve and a calcified coronary artery. This patient had sudden cardiac death few months after this radiography had been taken. We present here a case of coronary calcification that can be seen through simple chest radiography. Such images are not usually seen, although the risk of vascular calcification is high in this population, and is closely related to CV risk. Chest radiographs, nearly universally available provide a method for assessing coronary artery calcification. Such a finding is intriguing and should alert nephrologists and cardiologists for the high risk of CV death in these patients.

The association between mortality and abdominal aortic calcification and relation between its progression and serum calcium concentration in chronic hemodialysis patients

Background

The composite summary score (range, 0–24) of abdominal aortic calcification (AAC) devised by Kauppila et al is a simple method of assessing AAC severity. However, few studies have been conducted to determine an optimal AAC cutoff score for the prediction of mortality or to investigate the relation between mineral metabolism and AAC progression using the scoring system.

Methods

The medical records of 112 patients on hemodialysis who had undergone simple lateral lumbar radiography every 6 months from August 2009 were reviewed. Patients were followed until November 2012, and the relationship between the degree of AAC at baseline and mortality was evaluated. In addition, the relationship between the progression of AAC and serum concentrations of calcium and phosphate was evaluated in the 75 patients who were successfully followed until November 2012.

Results

The mean AAC score at baseline was 5.5±4.8, and the cutoff calcification score for the prediction of mortality was 7.75 (sensitivity=61%, specificity=81%). Patients were allocated to Group A (baseline total calcification score ≤8.0, n=85) or Group B (baseline total calcification score>8.0, n=27), and multivariate analysis showed that Group B was an independent risk factor of all-cause mortality and cardiovascular events. Of the 75 patients successfully followed, 51 showed AAC progression (Group 1) and 24 showed no change or improvement (Group 2). Group 1 was found to have significantly higher mean serum corrected calcium levels during the 2^nd year and 3^rd year of follow-up than Group 2. Furthermore, repeated-measures analysis of variance showed higher monthly corrected calcium concentrations (P=0.099) and mean corrected calcium levels during the 1^st year, 2^nd year, and 3^rd year of follow-up (P=0.062) in Group 1, but without statistical significance. The cutoff values of mean corrected calcium of the 2^nd year and 3^rd year for the prediction of AAC progression during follow-up years were 8.96 mg/dL and 9.45 mg/dL, respectively. Serum phosphate levels and corrected calcium×phosphate values were similar in Groups 1 and 2.

Conclusion

Patients with an AAC score of>8 at baseline seem to be at higher risk of mortality during follow-up. Of the serum variables examined, such as corrected calcium, phosphate, and corrected calcium×phosphate, corrected calcium was found to be marginally associated with AAC progression. However, a larger-scale prospective study is required to confirm our findings.

Protein-energy wasting, as well as overweight and obesity, is a long-term risk factor for mortality in chronic hemodialysis patients

INTRODUCTION

In patients with end-stage renal disease on chronic hemodialysis (HD), protein-energy wasting (PEW) is very common and is associated with increased morbidity and mortality. Evaluation of nutritional status should be performed regularly in all such patients, using multiple methods. In this study, we analyzed the influence of several nutritional markers on long-term (5 years) survival of HD patients in one center. This is the first study on the long-term influence of nutritional status on mortality in dialysis patients ever conducted in Romania.

MATERIALS AND METHODS

We included all prevalent HD patients in our center. Those with ongoing acute illnesses and with inflammation (C-reactive protein ≥ 6.0 mg/l) were excluded. In the remaining subjects (N = 149, 82 males, mean age 55 years old), we performed the following measurements of nutritional status: estimation of dietary protein intake by normalized protein equivalent of nitrogen appearance (nPNA), subjective global assessment (SGA), body mass index (BMI), tricipital skinfold thickness, mid-arm circumference, assessment of body composition by bioelectrical impedance analysis (BIA), and pre-dialysis serum creatinine, albumin, and total cholesterol. We used receiver operating characteristic curves to determine the cutoff points for most of the variables, and we applied the Kaplan-Meier estimator and the Cox's proportional hazards model (stepwise method) to analyze the influence of these variables on survival.

RESULTS

In univariate analysis, general factors including age ≥ 65 years, male gender, dialysis vintage ≥ 2 years, and the presence of diabetes and heart failure were all significant predictors of mortality. Among nutritional parameters, BMI ≥ 25 kg/m(2), SGA-B (mild PEW), nPNA < 1.15 g/kg per day, and the BIA-derived phase angle (PhA) <5.58° were also significantly associated with reduced survival. All of these factors maintained statistical significance in multivariate analysis, except for male gender and heart failure.

CONCLUSION

We showed that low values of SGA, nPNA, and PhA independently predict mortality in HD patients. In conjunction with an earlier study, we demonstrated that the relative risk of death associated with these markers is highest during the first year of monitoring and it decreases in the following 4 years, although it still remains significantly increased. On the other hand, overweight and obesity were also associated with lower survival after 5 years, whereas this association was not apparent after 1 year.

Predicting risk of mortality in dialysis patients: a retrospective cohort study evaluating the prognostic value of a simple chest X-ray

BACKGROUND

Clinical outcomes of dialysis patients are variable, and improved knowledge of prognosis would inform decisions regarding patient management. We assessed the value of simple, chest X-ray derived measures of cardiac size (cardiothoracic ratio (CTR)) and vascular calcification (Aortic Arch Calcification (AAC)), in predicting death and improving multivariable prognostic models in a prevalent cohort of hemodialysis patients.

METHODS

Eight hundred and twenty-four dialysis patients with one or more postero-anterior (PA) chest X-ray were included in the study. Using a validated calcification score, the AAC was graded from 0 to 3. Cox proportional hazards models were used to assess the association between AAC score, CTR, and mortality. AAC was treated as a categorical variable with 4 levels (0,1,2, or 3). Age, race, diabetes, and heart failure were adjusted for in the multivariable analysis. The criterion for statistical significance was p<0.05.

RESULTS

The median CTR of the sample was 0.53 [IQR=0.48,0.58] with calcification scores as follows: 0 (54%), 1 (24%), 2 (17%), and 3 (5%). Of 824 patients, 152 (18%) died during follow-up. Age, sex, race, duration of dialysis, diabetes, heart failure, ischemic heart disease and baseline serum creatinine and phosphate were included in a base Cox model. Both CTR (HR 1.78[1.40,2.27] per 0.1 unit change), area under the curve (AUC)=0.60[0.55,0.65], and AAC (AAC 3 vs 0 HR 4.35[2.38,7.66], AAC 2 vs 0 HR 2.22[1.41,3.49], AAC 1 vs 0 HR 2.43[1.64,3.61]), AUC=0.63[0.58,0.68]) were associated with death in univariate Cox analysis. CTR remained significant after adjustment for base model variables (adjusted HR 1.46[1.11,1.92]), but did not increase the AUC of the base model (0.71[0.66,0.76] vs. 0.71[0.66,0.76]) and did not improve net reclassification performance (NRI=0). AAC also remained significant on multivariable analysis, but did not improve net reclassification (NRI=0). All ranges were based on 95% confidence intervals.

CONCLUSIONS

Neither CTR nor AAC assessed on chest x-ray improved prediction of mortality in this prevalent cohort of dialysis patients. Our data do not support the clinical utility of X-ray measures of cardiac size and vascular calcification for the purpose of mortality prediction in prevalent hemodialysis patients. More advanced imaging techniques may be needed to improve prognostication in this population.

The prognostic value of abdominal aortic calcification in peritoneal dialysis patients

OBJECTIVE

This study evaluated the prognostic value of the aortic calcification index (ACI), an estimate of abdominal aortic calcification by plain abdominal computed tomography (CT), in terms of left ventricular (LV) diastolic dysfunction, mortality, and nonfatal cardiovascular (CV) events in peritoneal dialysis (PD) patients.

METHOD

PD patients who received both abdominal CT and echocardiography were divided into a low-ACI group (n=46) and a high-ACI group (n=46).

RESULTS

During follow-up (median, 35.2 months; range, 3.6-111.3), 30 patients (32.6%) died and 10 patients (10.9%) developed nonfatal cardiovascular (CV) events. The 5-year event-free survival rates for mortality and nonfatal CV events were significantly lower in the high-ACI group compared with those in the low-ACI group (35.7% vs. 64.1%, P = 0.01). The ACI was positively correlated with left atrial diameter and ratio of peak early transmitral flow velocity to peak early diastolic mitral annular velocity (E/E' ratio; a marker of left ventricular diastolic function). Using multivariate analyses, the high-ACI group (vs. low-ACI group, HR 5.25, 95% CI 1.77-15.58, P = 0.003) and increased E/E' ratio (HR 1.16, 95% CI 1.03-1.31, P = 0.013) were independent predictors for mortality and CV events. The ACI provided a higher predictive value for adverse outcomes (AUC = 0.755, P = 0.002) than the E/E' ratio (AUC = 0.543, P = 0.61).

CONCLUSION

The ACI was significantly associated with left ventricular diastolic dysfunction and predicted all-cause mortality and nonfatal CV events in PD patients.