Coronary Artery Calcification, Cardiovascular Events, and Death: A Prospective Cohort Study of Incident Patients on Hemodialysis

Abstract

BackgroundCoronary calcification in patients with end-stage renal disease (ESRD) is associated with an increased risk of cardiovascular outcomes and death from all causes. Previous evidence has been limited by short follow-up periods and inclusion of a heterogeneous cluster of events in the primary analyses.ObjectiveTo describe coronary calcification in patients incident to ESRD, and to identify whether calcification predicts vascular events or death.DesignProspective substudy of an inception cohort.SettingTertiary care haemodialysis centre in Ontario (St Joseph’s Healthcare Hamilton).ParticipantsPatients starting haemodialysis who were new to ESRD.MeasurementsAt baseline, clinical characterization and spiral computed tomography (CT) to score coronary calcification by the Agatston-Janowitz 130 scoring method. A primary outcome composite of adjudicated stroke, myocardial infarction, or death.MethodsWe followed patients prospectively to identify the relationship between cardiac calcification and subsequent stroke, myocardial infarction, or death, using Cox regression.ResultsWe recruited 248 patients in 3 centres to our main study, which required only biochemical markers. Of these 164 were at St Joseph’s healthcare, and eligible to participate in the substudy; of these, 51 completed CT scanning (31 %). Median follow up was 26 months (Q1, Q3: 14, 34). The primary outcome occurred in 16 patients; 11 in the group above the median and 5 in the group below (p = 0.086). There were 26 primary outcomes in 16 patients; 20 (77 %) events in the group above the coronary calcification median and 6 (23 %) in the group below (p = 0.006). There were 10 deaths; 8 in the group above the median compared with 2 in the group below (p = 0.04). The hazard ratios for coronary calcification above, compared with below the median, for the primary outcome composite were 2.5 (95 % CI 0.87, 7.3; p = 0.09) and 1.7 (95 % CI 0.55, 5.4; p = 0.4), unadjusted and adjusted for age, respectively. For death, the hazard ratios were 4.6 (95 % CI 0.98, 21.96; p = 0.054) and 2.4 (95 % CI 0.45, 12.97; p = 0.3) respectively.LimitationsWe were limited by a small sample size and a small number of events.ConclusionsRespondent burden is high for additional testing around the initiation of dialysis. High coronary calcification in patients new to ESRD has a tendency to predict cardiovascular outcomes and death, though effects are attenuated when adjusted for age.

Impact of vascular calcification on cardiovascular mortality in hemodialysis patients: clinical significance, mechanisms and possible strategies for treatment

“…As to the relationship between coronary artery calcification score (CACS) and clinical outcomes, dialysis patients with higher CACS showed significantly higher rate of cardiovascular and all-cause mortality compared with those with mild or no CACS (Fig. 1) [7][8][9][10][11][12][13]. In these reports, cardiovascular events were also significantly correlated with high CACS.…”

“…Vascular calcification affects on the future cardiovascular events and/or mortality in dialysis patients [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Several clinical trials to aim to improve cardiovascular events and/or mortality in dialysis patients have been planned or reported.…”

Coronary Artery Calcification and Risk of Cardiovascular Disease and Death Among Patients With Chronic Kidney Disease

“…21,27 Previous studies suggested that serum calcium and phosphate were associated with risk of CAC independent of traditional risk factors in CKD patients. 5,27 High intracellular phosphorus promotes the mineralization of vascular smooth muscle cells and medial artery calcification 28,29 Medial artery calcification is more prevalent in patients with CKD 30,31 even though the atherosclerotic intimal calcification associated with cellular necrosis, inflammation, lipid deposition, and vascular occlusion is also present in CKD patients.…”

Factors and Outcome of Renal Osteodystrophy-Associated Initial Fragility Fracture in End-Stage Renal Disease Patients

“…Bone or cartilage structure fracture was defined as continuous bone interruption including epiphyseal separation, and evaluated by X-ray or CT. Radiological findings were analyzed by two observers blinded to clinical data, with an interobserver concordance of 95%. Vascular calcification was determined with a CT value of vessel of 130 or higher by CT scan [13]. All subjects underwent echocardiography on a Hewlett-Packard Sonos 100 device equipped with a 2.25-MHz probe to verify the presence of cardiac valvular calcification, if ≥1 mm strong echo occurred in aortic and mitral, tricuspid leaf, or disc ring as assessed by Doppler echocardiography [14].…”