Coronary artery calcium and multiparametric cardiovascular risk assessment in non-dialysis chronic kidney disease

Cardiovascular disease is a leading cause of mortality in chronic kidney disease (CKD), but whether impaired renal function independently increases coronary artery calcium (CAC) burden in patients with comparable cardiovascular referral indications remains uncertain. This retrospective cross-sectional study included 206 adults who underwent coronary computed tomography angiography (CCTA) with simultaneous Agatston scoring at the Institute for Cardiovascular Diseases of Vojvodina between 2020 and 2025. Patients were classified as having eGFR-defined non-dialysis CKD stages 3-5 (n=110; estimated glomerular filtration rate [eGFR] ≤59 mL/min/1.73 m²) or preserved renal function (n=96; eGFR ≥60 mL/min/1.73 m²). Both groups were drawn from the same cardiovascular referral population. The primary outcome was total Agatston score, while secondary analyses included Agatston severity categories, significant vessel-level stenosis, calcified coronary segment count, eGFR-Agatston correlation, and predictors of severe CAC. Total Agatston scores did not differ significantly between CKD and control groups (median 248.5 vs. 198.0; p=0.240), and severe calcification was similarly frequent (40.0% vs. 41.6%). Vessel-level stenosis, calcified segment distribution, and the eGFR-Agatston correlation were also non-significant. In multivariable logistic regression adjusted for age, sex, hypertension, diabetes, and prior coronary artery bypass grafting (CABG), CKD was not independently associated with severe CAC. However, CKD patients showed a markedly more adverse cardiovascular phenotype, including more hypertension, angina, peripheral arterial disease, prior CABG, lower left ventricular ejection fraction (LVEF), higher right ventricular systolic pressure (RVSP), and more severe valvular disease. These findings suggest that CAC scoring alone does not capture the multidimensional cardiovascular burden of non-dialysis CKD and should be integrated with echocardiographic and systemic vascular assessment in high-risk referral populations.