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 (arterial) calcification (VC), particularly coronary artery calcification (CAC), which can be observed even in very young dialysis patients, who lack the typical vascular damage risk factors of hypertension, dyslipidemia, and smoking [1-5]. Calcium can be deposited into either or both of 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 the endothelium and smooth muscle layers.
The prevalence of VC among patients with CKD, especially those on dialysis, is extremely high. The prevalence is generally the highest among individuals with lower estimated glomerular filtration rates (eGFRs), and it is assumed that, as GFR falls, the prevalence and severity of VC rise. 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].
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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