Vascular calcification in chronic kidney disease
- Behdad Afzali, MRCP, PhD, PGDip, FHEA, MAcadMEd
Behdad Afzali, MRCP, PhD, PGDip, FHEA, MAcadMEd
- Wellcome Trust Intermediate Research Fellow
- King's College Honorary Consultant Nephrologist
- Guy's and St Thomas's Hospitals, NHS Trust, UK
- Guest Researcher, National Institutes of Health, USA
- David JA Goldsmith, MA, FRCP
David JA Goldsmith, MA, FRCP
- Department of Nephrology and Transplantation
- Guy's Hospital, London
The most common cause of death in dialysis patients is cardiovascular disease (CVD). This may be due in part to excess vascular calcification (VC), particularly coronary artery calcification (CAC), which can be observed even in very young dialysis patients [1-5]. Calcium can be deposited into either the medial or intimal layers of the vasculature.
The epidemiology, detection, and clinical significance of VC for patients with chronic kidney disease (CKD) are discussed in this topic review. The definition, pathogenesis, and molecular biology of VC are discussed separately. (See "Biology of vascular calcification in chronic kidney disease".)
The treatment of hyperphosphatemia and hyperparathyroidism associated with CKD and other issues associated with mineral and bone disease associated with CKD are also discussed elsewhere. (See "Treatment of hyperphosphatemia in chronic kidney disease" and "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in adult predialysis patients with chronic kidney disease" and "Management of secondary hyperparathyroidism and mineral metabolism abnormalities in dialysis patients" and "Overview of chronic kidney disease-mineral bone disease (CKD-MBD)" and "Adynamic bone disease associated with chronic kidney disease".)
Calcification in association with atherosclerosis is not a new phenomenon. The Horus study revealed atherosclerosis in 34 percent of mummies from four geographical regions or populations that spanned over 4000 years . In ancient times, the prevalence of atherosclerosis may have been due not only to dietary factors, but also to chronic infection-inflammation. Calcification may be considered a classical response to injury to endothelium and smooth muscle layers.
The prevalence of VC among patients with CKD, especially those on dialysis, is extremely high. The prevalence of VC detected by computed tomographic (CT) scanning is >80 percent among dialysis patients [1-3,7-22]. The reported prevalence among CKD patients who are not on dialysis is 47 to 83 percent [21,23-28]. The prevalence is generally the highest among individuals with lower estimated glomerular filtration rates (eGFRs). Among patients with reduced eGFR <60 mL/min per 1.73 m2, calcification is more prevalent, more severe, and progresses at a faster rate than in the general population. By contrast, among patients who have GFR ≥60 mL/min per 1.73 m2 who have moderately increased albuminuria (formerly called "microalbuminuria"), the risk is the same as among patients without CKD [24,25].
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- RISK FACTORS
- Increasing age and dialysis vintage
- Positive calcium and phosphate balance and calcium intake
- Vitamin D therapy
- Oral antagonists of vitamin K (eg, warfarin)
- DETECTION AND QUANTIFICATION
- VASCULAR CALCIFICATION AND CARDIOVASCULAR DISEASE
- CLINICAL SIGNIFICANCE
- PREVENTION AND TREATMENT
- Net calcium balance
- Kidney transplantation
- Additional therapies
- SUMMARY AND RECOMMENDATIONS