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Assessment of Vascular Function in Patients With Chronic Kidney Disease
Published on: June 16, 2014
Inverse J-shaped relation between coronary arterial calcium density and mortality in advanced chronic kidney disease
Hideyuki Mukai1, Lu Dai1, Zhimin Chen1
1Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Campus Flemingsberg, Stockholm, Sweden.
Insights
In end-stage renal disease patients, higher coronary artery calcium (CAC) volume and density are linked to increased mortality risk. This highlights CAC indices as crucial predictors for cardiovascular disease events in this high-risk population.
Area of Science:
- Cardiology
- Nephrology
- Radiology
Background:
- Coronary artery calcium (CAC) score, derived from cardiac computed tomography (CT), comprises CAC volume and density.
- In the general population, CAC volume correlates positively with cardiovascular disease (CVD) events, while CAC density correlates inversely, suggesting lower density indicates plaque instability.
- The association of CAC indices with mortality risk in patients with end-stage renal disease (chronic kidney disease Stage 5, CKD5) requires investigation.
Purpose of the Study:
- To analyze the associations of CAC indices (volume and density) with all-cause mortality risk in patients with CKD5.
- To explore the relationship between CAC indices and vascular calcification in CKD5 patients.
Main Methods:
- A cohort of 296 CKD5 patients underwent cardiac CT. Baseline assessments included Framingham risk score (FRS), CVD, protein-energy wasting (PEW), high-sensitivity C-reactive protein (hsCRP), and interleukin-6 (IL-6).
- All-cause mortality and renal transplantation were tracked over a median of 35 months using competing-risk regression models.
- Vascular calcification was assessed in arterial biopsies from 111 patients.
Main Results:
- Patients in the middle tertile of CAC density exhibited the highest CAC score, CAC volume, and other risk factors (age, CVD, PEW, FRS, hsCRP, IL-6).
- Higher CAC density (middle and high tertiles) was independently associated with increased mortality (sHR 10.7 and 8.9, respectively), irrespective of CAC volume.
- Elevated CAC volume (high tertile) also independently predicted increased mortality (sHR 8.9), independent of CAC density.
- Arterial media calcification was prevalent and correlated with both CAC volume and density.
Conclusions:
- In CKD5 patients, mortality risk increased linearly with CAC score and CAC volume.
- An inverse J-shaped pattern was observed for CAC density, with the highest crude mortality rate in the middle tertile.
- Both CAC volume and density are associated with the extent of arterial media calcification and independently predict mortality in CKD5 patients.
Background:
The coronary artery calcium (CAC) score from cardiac computed tomography (CT) is a composite of CAC volume and CAC density. In the general population, CAC volume is positively and CAC density inversely associated with cardiovascular disease (CVD) events, implying that decreased CAC density reflects atherosclerotic plaque instability. We analysed associations of CAC indices with mortality risk in patients with end-stage renal disease [chronic kidney disease Stage 5 (CKD5)].
Methods:
In 296 CKD5 patients undergoing cardiac CT (median age 55 years, 67% male, 19% diabetes, 133 dialysed), the Framingham risk score (FRS), presence of CVD and protein-energy wasting (PEW; subjective global assessment) and high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) were determined at baseline. During follow-up for a median of 35 months, 51 patients died and 75 patients underwent renal transplantation. All-cause mortality risk was analysed with competing-risk regression models. Vascular calcification was analysed in biopsies of the arteria epigastrica inferior in 111 patients.
Results:
Patients in the middle tertile of CAC density had the highest CAC score, CAC volume, age, CVD, PEW, FRS, hsCRP and IL-6. In competing risk analysis, the middle {subhazard ratio [sHR] 10.7 [95% confidence interval (CI) 2.0-57.3]} and high [sHR 8.9 (95% CI 1.5-51.8)] tertiles of CAC density associated with increased mortality, independent of CAC volume. The high tertile of CAC volume, independent of CAC density, associated with increased mortality [sHR 8.9 (95% CI 1.5-51.8)]. Arterial media calcification was prominent and associated with CAC volume and CAC density.
Conclusions:
In CKD5, mortality increased linearly with higher CAC score and CAC volume whereas for CAC density an inverse J-shaped pattern was observed, with the crude mortality rate being highest for the middle tertile of CAC density. CAC volume and CAC density were associated with the extent of arterial media calcification.
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