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Total and Individual Coronary Artery Calcium Scores as Independent Predictors of Death in HD Patients. Reference: Shantouf SR, Budoff MJ, Ahmadi N, et al. Total and individual coronary artery calcium scores as independent predictors of death in HD patients.
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Total and Individual Coronary Artery Calcium Scores as Independent Predictors of Death in HD Patients Reference: Shantouf SR, Budoff MJ, Ahmadi N, et al. Total and individual coronary artery calcium scores as independent predictors of death in HD patients. Am J Nephrol. 2010;31:419–425.
Introduction • Cardiovascular disease most commonly occurs in patients with end-stage renal disease who are on hemodialysis (HD). • Potential contributing factors to this elevated incidence include traditional risk factors such as age, gender, dyslipidemia, diabetes mellitus (DM) and several nontraditional risk factors such as hyperparathyroidism, malnutrition, inflammation, coronary artery calcium (CAC), and mineral disarrays, specifically elevated levels of phosphorus and calcium-phosphorus product. • The ability to detect and quantify coronary artery calcium using currently available imaging method, non-enhanced computed tomography (CT), has created a signifi cant interest in developing appropriate applications for various clinical settings. • In a recent study, it has been proved that CAC is the strong predictor of coronary heart disease among major racial and ethnic groups.
Introduction • Block et al. showed that patients on calcium-based phosphate binder (CBPB) entailed a greater risk of death, suggesting that treatment with a CBPB may contribute to the vascular calcification burden. • Chertowet al. in a randomized study containing 200 maintenance HD (MHD) patients, administered with CPBP and sevelamer, showed that median CAC increased significantly in the CBPB group. • Cardiac CT and all-cause mortality in relation to baseline cardiac CT scan were assessed comparing four groups defined as CAC 0, CAC 1–100, CAC 101–400 and CAC 400+. • Table 1 summarizes the baseline characteristics of the subjects.
Patients and Methods • The Nutritional and Inflammatory Evaluation of Dialysis patients (NIED) study was a prospective cohort study conducted to determine the nutritional and inflammatory states in MHD patients. • The age of the patients included in the trial were 18 years and above. • All the subjects were undergoing MHD treatment thrice a week and their dialysis membranes were regularly reused. • New subjects were assessed for malnutrition and inflammatory variables including biochemical markers, anthropometric measurements, hospitalization rates and mortality. • Severity of comorbidities was assessed using CharlsonComorbidity Index. • Demographics of patients and their use of phosphate binders HMG CoAreductase inhibitors were also analyzed.
Dialysis and Laboratory Data • Dialysis vintage time and weekly dialysis dose of each patient was evaluated. • Laboratory data such as serum levels of calcium, phosphorus, intact parathyroid hormone and albumin were obtained through regular automated methods. • The average values of tests within 13-week period were taken for each study round.
Study-Specifi c Laboratory Tests • Laboratory tests such as serum high-sensitivity C-reactive protein, two proinfl ammatory cytokines, interleukin- 6 (IL-6) and tumor necrosis factor (TNF-α), serum total cholesterol, LDL-C, HDL-C, as well as homocysteine levels were measured from fasting samples in all patients.
Computed Tomography • An E-speed electron beam scanner was used to conduct CT studies. Coronary arteries were imaged rapid acquisition of approximately 30–40 contiguous images of 3 mm slice thickness without gap during mid-diastole. • Calcium was considered to be present in the coronary artery if its density was found to be >130 Hounsfield units. • Table 2 summarizes characteristics of four groups of patients. • Results showed statistically signifi cant difference in age, gender, DM, CharlsonComorbidity Index and intact parathyroid hormone. • However, there was no difference observed in vintage time, BMI, serum albumin, statin therapy, and hypertension status, family history of heart disease, calcium phosphate product, inflammatory markers, and uses of CBPB among the four groups (see Table 2). • Among 166 patients, 50 deaths were observed at the end of the follow-up. Thirty deaths occurred in the CAC 400+ group and two deaths occurred in CAC 0 group.
Conclusion • Cardiovascular morbidity and mortality are highly prevalent in HD patients and have been associated with vascular calcifi cations. • Common complications of CKD include serum elevated calcium and phosphorus, diabetes, smoking status, vintage time and secondary hyperparathyroidism. • The average vintage time for the 166 patients was 3.58 years from start of dialysis to CT date. • The CAC scores of 100+ were a strong predictor of mortality. • Thus, ultrasound imaging appears to have great potential application for enhanced diagnosis of coronary artery calcifi cation and may serve to guide new techniques in the treatment of coronary artery disease.
