Incidence and progression of coronary calcification in chronic kidney disease: the Multi-Ethnic Study of Atherosclerosis
2009; Elsevier BV; Volume: 76; Issue: 9 Linguagem: Inglês
10.1038/ki.2009.298
ISSN1523-1755
AutoresBryan Kestenbaum, Kathryn L. Adeney, Ian H. de Boer, Joachim H. Ix, Michael G. Shlipak, David S. Siscovick,
Tópico(s)Cardiovascular Function and Risk Factors
ResumoWe studied the incidence and progression of coronary artery calcification in people with early chronic kidney disease. We used a cohort of 562 adult patients with chronic kidney disease who had an estimated glomerular filtration rate of <60 ml/min/1.73 m2, in a community-based study of people without clinical cardiovascular disease, the Multi-Ethnic Study of Atherosclerosis. The majority had stage 3 disease. Coronary artery calcification was measured at baseline and again approximately 1.6 or 3.2 years later. The prevalence of coronary artery calcification at baseline was 66%, and its adjusted prevalence was 24% lower in African Americans as compared to Caucasians. The incidence of coronary artery calcification was 6.1% per year in women and 14.8% in men. Coronary artery calcification progressed in approximately 17% of subjects per year across all subgroups, and diabetes was associated with a 65% greater adjusted risk of progression. Male gender and diabetes were the only factors associated with adjusted coronary artery calcification incidence and progression, respectively. Our study shows that coronary artery calcification is common in people with stage 3 disease, progresses rapidly, and may contribute to cardiovascular risk. We studied the incidence and progression of coronary artery calcification in people with early chronic kidney disease. We used a cohort of 562 adult patients with chronic kidney disease who had an estimated glomerular filtration rate of <60 ml/min/1.73 m2, in a community-based study of people without clinical cardiovascular disease, the Multi-Ethnic Study of Atherosclerosis. The majority had stage 3 disease. Coronary artery calcification was measured at baseline and again approximately 1.6 or 3.2 years later. The prevalence of coronary artery calcification at baseline was 66%, and its adjusted prevalence was 24% lower in African Americans as compared to Caucasians. The incidence of coronary artery calcification was 6.1% per year in women and 14.8% in men. Coronary artery calcification progressed in approximately 17% of subjects per year across all subgroups, and diabetes was associated with a 65% greater adjusted risk of progression. Male gender and diabetes were the only factors associated with adjusted coronary artery calcification incidence and progression, respectively. Our study shows that coronary artery calcification is common in people with stage 3 disease, progresses rapidly, and may contribute to cardiovascular risk. Vascular and soft tissue calcification is common among individuals with chronic kid ney disease (CKD) and may represent an important mechanism linking kidney dysfunction with cardiovascular risk.1.Blacher J. Guerin A.P. Pannier B. et al.Arterial calcifications, arterial stiffness, and cardiovascular risk in end-stage renal disease.Hypertension. 2001; 38: 938-942Crossref PubMed Scopus (1234) Google Scholar, 2.Block G.A. Spiegel D.M. Ehrlich J. et al.Effects of sevelamer and calcium on coronary artery calcification in patients new to hemodialysis.Kidney Int. 2005; 68: 1815-1824Abstract Full Text Full Text PDF PubMed Scopus (718) Google Scholar, 3.Qunibi W.Y. Abouzahr F. Mizani M.R. et al.Cardiovascular calcification in Hispanic Americans (HA) with chronic kidney disease (CKD) due to type 2 diabetes.Kidney Int. 2005; 68: 271-277Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 4.Russo D. Palmiero G. De Blasio A.P. et al.Coronary artery calcification in patients with CRF not undergoing dialysis.Am J Kidney Dis. 2004; 44: 1024-1030Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar Among individuals with end-stage renal disease, coronary artery calcification (CAC) is highly prevalent, progresses rapidly, and is associated with an increased risk of death.1.Blacher J. Guerin A.P. Pannier B. et al.Arterial calcifications, arterial stiffness, and cardiovascular risk in end-stage renal disease.Hypertension. 2001; 38: 938-942Crossref PubMed Scopus (1234) Google Scholar, 2.Block G.A. Spiegel D.M. Ehrlich J. et al.Effects of sevelamer and calcium on coronary artery calcification in patients new to hemodialysis.Kidney Int. 2005; 68: 1815-1824Abstract Full Text Full Text PDF PubMed Scopus (718) Google Scholar, 5.Block G.A. Raggi P. Bellasi A. et al.Mortality effect of coronary calcification and phosphate binder choice in incident hemodialysis patients.Kidney Int. 2007; 71: 438-441Abstract Full Text Full Text PDF PubMed Scopus (672) Google Scholar, 6.Chertow G.M. Burke S.K. Raggi P. Sevelamer attenuates the progression of coronary and aortic calcification in hemodialysis patients.Kidney Int. 2002; 62: 245-252Abstract Full Text Full Text PDF PubMed Scopus (1327) Google Scholar Even young dialysis patients with few traditional cardiovascular risk factors have extensive CAC.7.Goodman W.G. Goldin J. Kuizon B.D. et al.Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis.N Engl J Med. 2000; 342: 1478-1483Crossref PubMed Scopus (2434) Google Scholar Among nondialyzed individuals with CKD, the rates of incidence and progression of CAC are not comprehensively described. Previous case series describing calcification in non-dialysis CKD were largely cross-sectional, spanned a wide range of kidney function, and included relatively few subjects.3.Qunibi W.Y. Abouzahr F. Mizani M.R. et al.Cardiovascular calcification in Hispanic Americans (HA) with chronic kidney disease (CKD) due to type 2 diabetes.Kidney Int. 2005; 68: 271-277Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 4.Russo D. Palmiero G. De Blasio A.P. et al.Coronary artery calcification in patients with CRF not undergoing dialysis.Am J Kidney Dis. 2004; 44: 1024-1030Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 8.Ix J.H. Katz R. Kestenbaum B. et al.Association of mild to moderate kidney dysfunction and coronary calcification.J Am Soc Nephrol. 2008; 19: 579-585Crossref PubMed Scopus (54) Google Scholar, 9.Kramer H. Toto R. Peshock R. et al.Association between chronic kidney disease and coronary artery calcification: the Dallas Heart Study.J Am Soc Nephrol. 2005; 16: 507-513Crossref PubMed Scopus (232) Google Scholar, 10.Mikami S. Hamano T. Fujii N. et al.Serum osteoprotegerin as a screening tool for coronary artery calcification score in diabetic pre-dialysis patients.Hypertens Res. 2008; 31: 1163-1170Crossref PubMed Scopus (52) Google Scholar, 11.Dellegrottaglie S. Saran R. Gillespie B. et al.Prevalence and predictors of cardiovascular calcium in chronic kidney disease (from the Prospective Longitudinal RRI-CKD Study).Am J Cardiol. 2006; 98: 571-576Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 12.Tomiyama C. Higa A. Dalboni M.A. et al.The impact of traditional and non-traditional risk factors on coronary calcification in pre-dialysis patients.Nephrol Dial Transplant. 2006; 21: 2464-2471Crossref PubMed Scopus (112) Google Scholar Therefore, prevalence estimates for coronary calcification in CKD vary considerably. Previous studies also included individuals with prevalent cardiovascular disease who may have already had extensive calcification. In this descriptive cohort study, we examined the natural history of CAC in a multiethnic population with predominantly stage III CKD. Study participants were free of known clinical cardiovascular disease at baseline, providing an opportunity to describe the calcification process when it may be first developing. There were 684 Multi-Ethnic Study of Atherosclerosis (MESA) participants with an estimated glomerular filtration rate (GFR) of <60 ml/min per 1.73 m2 at baseline examination. Among this group, 562 (82%) participants returned for a follow-up computed tomography (CT) scan (Figure 1). Compared with returning participants, those who did not complete follow-up CT scanning were more likely to be diabetic (27 versus 15%), were African American (29 versus 18%), and had a modestly lower baseline estimated GFR (mean 49 versus 52 ml/min per 1.73 m2). Nonreturning participants also had higher baseline CAC scores (median 76 versus 28 Agatston units) compared with those who completed follow-up. Among the 122 nonreturning participants, 19 (16%) died during the follow-up period. Subsequent analyses were conducted among the 562 participants who completed follow-up CT scans. Among this study population, 98% had stage III CKD at baseline (median estimated GFR: 55.4 ml/min per 1.73 m2; interquartile range: 50.1, 57.3) and 19% had microalbuminuria. CAC was present at baseline in 66% of the MESA CKD study population. Compared with CKD participants without baseline CAC, CKD participants with prevalent CAC were older, more likely to be male, had lower HDL-cholesterol levels, lower estimated GFR, and a modestly greater urine albumin to creatinine ratio, (Table 1). African-American participants were significantly less likely to have prevalent CAC. After adjustment for demographics, diabetes, smoking, hypertension, body mass index, serum cholesterol levels, C-reactive protein, cystatin C, and urine albumin-to-creatinine ratio, African-American race remained statistically associated with a 24% lower prevalence of CAC (95% CI: 10–36% lower; P=0.002 for comparison with Caucasians). In contrast, the adjusted CAC prevalence among Chinese-American, Hispanic, and Caucasian participants with CKD was statistically indistinguishable. Older age, male sex, hypertension, and low-density lipoprotein levels were also statistically associated with a higher prevalence of CAC in the multivariable model.Table 1Baseline characteristics according to prevalent coronary calcification statusAll participantsStratified by presence of calcification(n = 562)No CAC (n = 192)Any CAC (n = 370)P-value*Statistically significant after Bonferroni's correction for multiple comparisons.Age (years)68.7 (8.7)63.9 (8.4)71.2 (7.9)<0.001*Statistically significant after Bonferroni's correction for multiple comparisons.Male gender222 (40)55 (29)167 (45)<0.001*Statistically significant after Bonferroni's correction for multiple comparisons.Race/ethnicity Caucasian306 (54)100 (52)206 (56) Chinese63 (11)22 (11)41 (11) African American100 (18)42 (22)58 (16) Hispanic93 (17)28 (15)65 (18)0.29BMI (kg/m2)28.4 (5.3)28.6 (5.4)28.3 (5.2)0.56Pre-hypertension72 (13)29 (15)43 (12)Hypertension400 (71)110 (57)291 (78)<0.001*Statistically significant after Bonferroni's correction for multiple comparisons.Family history of MI240 (47)78 (44)162 (48)0.45LDL cholesterol (mg per 100 ml)117.7 (32.7)114.6 (32.5)119.4 (32.7)0.10HDL cholesterol (mg per 100 ml)51.8 (15.1)54.1 (16.4)50.6 (14.3)0.01Impaired fasting glucose83 (15)23 (12)60 (16)Diabetes85 (15)28 (15)57 (15)0.36Smoking Never304 (55)114 (61)190 (51) Ever207 (37)58 (31)149 (40) Current45 (8)16 (9)29 (8)0.08Cystatin C (mg/l)1.19 (0.42)1.11 (0.34)1.24 (0.45)<0.001*Statistically significant after Bonferroni's correction for multiple comparisons.eGFR (ml/min per 1.73 m2)52.2 (7.9)53.2 (6.8)51.7 (8.4)0.02C-reactive protein (mg/l)aMedian (interquartile range). P-value based on comparison of log-transformed values.2.2 (1.0, 4.5)2.3 (1.1, 5.0)2.2 (0.9, 4.4)0.22Albumin/creatinine (mg/g)aMedian (interquartile range). P-value based on comparison of log-transformed values.6.6 (3.6, 17.8)4.9 (3.1, 10.8)7.8 (4.0, 23.4)0.001*Statistically significant after Bonferroni's correction for multiple comparisons.Microalbuminuria106 (19)26 (14)80 (22)0.02Serum phosphate (mg per 100 ml)3.53 (0.53)3.48 (0.57)3.56 (0.51)0.17Serum 25-hydroxyvitamin D (ng/ml)24.1 (13.9)22.5 (11.2)25.0 (15.2)0.07BMI, body mass index; CAC, coronary artery calcification; eGFR, estimated glomerular filtration rate; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MI, myocardial infarction.a Median (interquartile range). P-value based on comparison of log-transformed values.* Statistically significant after Bonferroni's correction for multiple comparisons. Open table in a new tab BMI, body mass index; CAC, coronary artery calcification; eGFR, estimated glomerular filtration rate; HDL, high-density lipoprotein; LDL, low-density lipoprotein; MI, myocardial infarction. We questioned whether the lower prevalence of CAC in African Americans with CKD might have been due to selection bias caused by the explicit use of race to calculate Modification of Diet in Renal Disease (MDRD) GFR. To address this concern, we created a second CKD study population, defined by an estimated GFR of <60 ml/min per 1.73 m2 using the equation eGFRcystatin=76.7 × (cystatin C)−1.19, which does not include race. In this cystatin C-based CKD population, African-American race was associated with a 27% lower (95% CI: 11–39%; P=0.001) adjusted prevalence of CAC. Among participants with prevalent calcification at baseline, the median CAC score was 120 Agatston units (interquartile range: 31, 377 units; Figure 2). There were 91 participants with CAC scores between 1 and 30 Agatston units. In the fully adjusted multivariate model, older age, male sex, and higher C-reactive protein levels were statistically associated with a greater amount of baseline CAC among participants with prevalent CAC, whereas African-American race was associated with a lower amount of baseline CAC. The median follow-up time between CT scans was 2.0 years (interquartile range: 1.5, 3.1). Incident CAC developed in 20% of CKD study participants without baseline CAC (N=39; estimated incidence rate: 8.5% per year). Incident CAC was more than twice as common in men than in women (14.8% per year in men and 6.1% per year in women; Table 2). In contrast, there were no detectable differences in incident CAC rates by race/ethnicity. After full adjustment, male sex was the only characteristic that was associated with a greater incidence of CAC (Table 2).Table 2Risk factors for incident coronary artery calcificationVariableUnadjusted IRR (95% CI)AdjustedaAdjusted for age, race, gender, and scanner pair. IRR (95% CI)AdjustedbAdjusted for all of the factors in the table plus scanner pair. IRR (95% CI)P-valuecP-value for fully adjusted model.Age (1 year older)1.02 (0.99, 1.05)1.01 (0.98, 1.04)1.01 (0.98, 1.05)0.38Race/ethnicity CaucasianReferenceReferenceReference Chinese1.95 (0.92, 4.14)2.13 (0.82, 5.50)2.09 (0.73, 5.98)0.17 African American1.45 (0.76, 2.77)1.05 (0.54, 2.03)0.84 (0.40, 1.76)0.64 Hispanic0.84 (0.31, 2.32)0.87 (0.31, 2.46)0.68 (0.24, 1.92)0.47Male gender2.43 (1.43, 4.12)2.26 (1.32, 3.88)2.27 (1.26, 4.09)0.006Diabetes1.82 (0.93, 3.55)1.44 (0.71, 2.92)1.08 (0.55, 2.14)0.82Current smoking2.03 (1.00, 4.12)2.05 (1.10, 3.83)1.66 (0.90, 3.07)0.11Hypertension1.49 (0.84, 2.66)1.32 (0.70, 2.51)1.12 (0.56, 2.26)0.74Body mass index (1 unit greater)1.03 (0.98, 1.09)1.07 (1.00, 1.13)1.06 (0.99, 1.13)0.10LDL cholesterol (10 mg per 100 ml greater)1.01 (0.93, 1.10)1.01 (0.93, 1.10)1.02 (0.93, 1.11)0.71HDL cholesterol (10 mg per 100 ml greater)0.87 (0.71, 1.07)0.98 (0.81, 1.19)1.03 (0.84, 1.26)0.76C-reactive protein (1 mg/l greater)1.00 (0.95, 1.06)1.01 (0.97, 1.06)1.00 (0.95, 1.05)0.95Cystatin C (0.2 mg/l greater)1.10 (0.98, 1.24)1.07 (0.93, 1.23)1.02 (0.87, 1.19)0.85Log albumin-to-creatinine ratio1.22 (1.04, 1.42)1.16 (0.98, 1.37)1.11 (0.93, 1.32)0.24CI, confidence interval; HDL, high-density lipoprotein; IRR, incidence rate ratio; LDL, low-density lipoprotein.N = 39 participants with incident coronary calcification.a Adjusted for age, race, gender, and scanner pair.b Adjusted for all of the factors in the table plus scanner pair.c P-value for fully adjusted model. Open table in a new tab CI, confidence interval; HDL, high-density lipoprotein; IRR, incidence rate ratio; LDL, low-density lipoprotein. N = 39 participants with incident coronary calcification. Among participants with prevalent CAC at baseline, the median absolute increase in CAC scores was +24 Agatston units per year (intraquartile range: +6, +66). The extent of CAC progression was strongly dependent on the baseline score; higher baseline Agatston scores were associated with higher absolute and lesser relative changes in CAC during follow-up (Figure 3). The dichotomous MESA definition of CAC progression was less dependent on the baseline score than was either absolute or relative change. On the basis of the MESA definition of CAC progression, 144 (39%) participants with prevalent CAC progressed during follow-up, corresponding to an estimated progression rate of 16.8% per year. CAC progression was not statistically associated with age, race, or sex (Figure 4). After adjustment, diabetic participants were ∼65% more likely to progress compared with nondiabetic participants (Table 3; 95% CI: 25–118% more likely). Estimated kidney function as defined by cystatin C levels was not associated with CAC progression. Substituting serum creatinine level or MDRD estimated GFR for cystatin C in the multivariate model for CAC progression did not yield significant results for either variable (P=0.58 for serum creatinine; P=0.60 for MDRD estimated GFR).Table 3Risk factors for progression of coronary artery calcificationVariableUnadjusted IRR (95% CI)AdjustedaAdjusted for age, race, gender, and scanner pair. IRR (95% CI)AdjustedbAdjusted for all of the factors in the table plus scanner pair. IRR (95% CI)P-valuecP-value for fully adjusted model.Age (1 year older)1.00 (0.98, 1.01)1.00 (0.98, 1.01)1.00 (0.98, 1.02)0.79Race/ethnicity CaucasianReferenceReferenceReference Chinese0.67 (0.39, 1.14)0.82 (0.46, 1.47)0.74 (0.41, 1.34)0.33 African American1.36 (1.03, 1.81)1.27 (0.94, 1.73)1.04 (0.75, 1.43)0.81 Hispanic1.07 (0.77, 1.48)1.04 (0.74, 1.47)0.95 (0.66, 1.38)0.79Male gender1.10 (0.87, 1.39)1.06 (0.84, 1.35)1.10 (0.84, 1.42)0.50Diabetes1.77 (1.40, 2.24)1.69 (1.31, 2.18)1.65 (1.25, 2.18)<0.001Current smoking1.38 (0.99, 1.90)1.36 (0.96, 1.92)1.40 (0.95, 2.04)0.09Hypertension1.11 (0.82, 1.50)1.08 (0.80, 1.47)0.95 (0.69, 1.33)0.78Body mass index (1 unit greater)1.01 (0.99, 1.04)1.00 (0.98, 1.03)1.00 (0.97, 1.02)0.78LDL cholesterol (10 mg per 100 ml greater)1.01 (0.98, 1.05)1.01 (0.98, 1.05)1.01 (0.98, 1.05)0.39HDL cholesterol (10 mg per 100 ml greater)0.97 (0.90, 1.06)1.00 (0.92, 1.09)1.02 (0.94, 1.12)0.60C-reactive protein (1 mg/l greater)1.02 (1.00, 1.04)1.01 (0.99, 1.03)1.01 (0.98, 1.03)0.60Cystatin C (0.2 mg/l greater)1.07 (1.04, 1.09)1.05 (1.03, 1.08)1.05 (0.99, 1.12)0.10Log albumin-to-creatinine ratio1.09 (1.02, 1.17)1.08 (1.01, 1.15)1.03 (0.95, 1.12)0.46CI, confidence interval; BMI, body mass index; HDL, high-density lipoprotein; IRR, incidence rate ratio; LDL, low-density lipoprotein.N = 144 participants with progression.a Adjusted for age, race, gender, and scanner pair.b Adjusted for all of the factors in the table plus scanner pair.c P-value for fully adjusted model. Open table in a new tab CI, confidence interval; BMI, body mass index; HDL, high-density lipoprotein; IRR, incidence rate ratio; LDL, low-density lipoprotein. N = 144 participants with progression. In a multiethnic cohort with predominantly stage III CKD and no clinically apparent cardiovascular disease, 66% of participants had prevalent CAC, confirming a high prevalence of subclinical coronary atherosclerosis and/or dystrophic calcification in this population. Compared with Caucasians with CKD, African Americans with CKD had a 24% lower adjusted prevalence of CAC. Incident CAC developed at a rate of 14.8% per year in men and 6.1% per year in women. Progression of existing CAC was statistically similar by race/ethnicity and sex, and was strongly associated with the presence of diabetes. These data provide population-based estimates of CAC rates among individuals with CKD and extend previous findings describing chronic kidney disease in the MESA population.8.Ix J.H. Katz R. Kestenbaum B. et al.Association of mild to moderate kidney dysfunction and coronary calcification.J Am Soc Nephrol. 2008; 19: 579-585Crossref PubMed Scopus (54) Google Scholar, 13.Adeney K.L. Siscovick D.S. Ix J.H. et al.Association of serum phosphate with vascular and valvular calcification in moderate CKD.J Am Soc Nephrol. 2009; 20: 381-387Crossref PubMed Scopus (337) Google Scholar, 14.Ix J.H. De Boer I.H. Peralta C.A. et al.Serum phosphorus concentrations and arterial stiffness among individuals with normal kidney function to moderate kidney disease in MESA.Clin J Am Soc Nephrol. 2009; 4: 609-615Crossref PubMed Scopus (136) Google Scholar, 15.Kramer H. Palmas W. Kestenbaum B. et al.Chronic kidney disease prevalence estimates among racial/ethnic groups: the Multi-Ethnic Study of Atherosclerosis.Clin J Am Soc Nephrol. 2008; 3: 1391-1397Crossref PubMed Scopus (41) Google Scholar In previous case series, prevalence estimates for CAC in CKD vary from 40 to 73%.3.Qunibi W.Y. Abouzahr F. Mizani M.R. et al.Cardiovascular calcification in Hispanic Americans (HA) with chronic kidney disease (CKD) due to type 2 diabetes.Kidney Int. 2005; 68: 271-277Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 4.Russo D. Palmiero G. De Blasio A.P. et al.Coronary artery calcification in patients with CRF not undergoing dialysis.Am J Kidney Dis. 2004; 44: 1024-1030Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar, 9.Kramer H. Toto R. Peshock R. et al.Association between chronic kidney disease and coronary artery calcification: the Dallas Heart Study.J Am Soc Nephrol. 2005; 16: 507-513Crossref PubMed Scopus (232) Google Scholar, 11.Dellegrottaglie S. Saran R. Gillespie B. et al.Prevalence and predictors of cardiovascular calcium in chronic kidney disease (from the Prospective Longitudinal RRI-CKD Study).Am J Cardiol. 2006; 98: 571-576Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 12.Tomiyama C. Higa A. Dalboni M.A. et al.The impact of traditional and non-traditional risk factors on coronary calcification in pre-dialysis patients.Nephrol Dial Transplant. 2006; 21: 2464-2471Crossref PubMed Scopus (112) Google Scholar For example, Russo et al.4.Russo D. Palmiero G. De Blasio A.P. et al.Coronary artery calcification in patients with CRF not undergoing dialysis.Am J Kidney Dis. 2004; 44: 1024-1030Abstract Full Text Full Text PDF PubMed Scopus (256) Google Scholar observed a 40% prevalence of CAC among 85 patients (mean age: 54 years) with stage III–V CKD who had no known cardiovascular disease or diabetes. Tomiyama et. al.12.Tomiyama C. Higa A. Dalboni M.A. et al.The impact of traditional and non-traditional risk factors on coronary calcification in pre-dialysis patients.Nephrol Dial Transplant. 2006; 21: 2464-2471Crossref PubMed Scopus (112) Google Scholar reported a 64% prevalence of CAC among 96 patients (mean age: 55 years) with an estimated creatinine clearance of 15–90 ml/min per 1.73 m2 from an outpatient nephrology clinic population in Brazil. Qunibi et al.3.Qunibi W.Y. Abouzahr F. Mizani M.R. et al.Cardiovascular calcification in Hispanic Americans (HA) with chronic kidney disease (CKD) due to type 2 diabetes.Kidney Int. 2005; 68: 271-277Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar reported prevalence rates of 38 and 73% among 55 Hispanic Americans with diabetic nephropathy and stages I–II and IV–V CKD, respectively (mean ages: 52 and 56 years, respectively). Our prevalence estimate from this somewhat older, relatively large, multiethnic sample without cardiovascular disease is within the range of previously reported rates. Estimates of the prevalence and extent of coronary calcification observed among patients with an estimated GFR of <60 ml/min per 1.73 m2 in this study were similar to estimates reported among patients with microalbuminuria in the same MESA population. Kramer et al.16.Kramer H. Jacobs Jr, D.R. Bild D, Post W, et al. Urine albumin excretion and subclinical cardiovascular disease. The Multi-Ethnic Study of Atherosclerosis.Hypertension. 2005; 46: 38-43Crossref PubMed Scopus (123) Google Scholar found an ∼66% prevalence of coronary calcification among MESA participants with microalbuminuria, defined using sex-specific cutoff points. The distributions of nonzero coronary calcium scores were also similar comparing microalbuminuria and estimated GFR of 300 were associated with 3.9-, 7.1-, and 6.8-fold higher risks of incident cardiovascular events, respectively, compared with a CAC score of 0.23.Detrano R. Guerci A.D. Carr J.J. et al.Coronary calcium as a predictor of coronary events in four racial or ethnic groups.N Engl J Med. 2008; 358: 1336-1345Crossref PubMed Scopus (2119) Google Scholar Although CAC may be less prevalent among African Americans, its existence more strongly predicts future cardiovascular risk in this race group. In a general cohort study of 14,812 adults, the association of CAC score with mortality was more than twofold higher among African Americans compared with the non-Hispanic Caucasian reference cohort.24.Nasir K. Shaw L.J. Liu S.T. et al.Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality.J Am Coll Cardiol. 2007; 50: 953-960Abstract Full Text Full Text PDF PubMed Scopus (129) Google Scholar Coronary calcification in the setting of early CKD may represent intimal atherosclerosis, medial vessel calcification, or both. Histological studies of epigastric arteries removed from chronic dialysis patients have shown evidence of medial arterial calcification.25.Moe S.M. O'Neill K.D. Duan D. et al.Medial artery calcification in ESRD patients is associated with deposition of bone matrix proteins.Kidney Int. 2002; 61: 638-647Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar Nontraditional risk factors, such as higher serum phosphate levels and greater intake of calcium containing oral phosphorous binders, are associated with coronary calcification scores in chronic dialysis patients,7.Goodman W.G. Goldin J. Kuizon B.D. et al.Coronary-artery calcification in young adults with end-stage renal disease who are undergoing dialysis.N Engl J Med. 2000; 342: 1478-1483Crossref PubMed Scopus (2434) Google Scholar,26.Raggi P. Boulay A. Chasan-Taber S. et al.Cardiac calcification in adult hemodialysis patients. A link between end-stage renal disease and cardiovascular disease?.J Am Coll Cardiol. 2002; 39: 695-701Abstract Full Text Full Text PDF PubMed Scopus (995) Google Scholar suggesting that at least some CAC might represent medial calcification in advanced kidney failure.27.Gross M.L. Meyer H.P. Ziebart H. et al.Calcification of coronary intima and media: immunohistochemistry, backscatter imaging, and x-ray analysis in renal and nonrenal patients.Clin J Am Soc Nephrol. 2007; 2: 121-134Crossref PubMed Scopus (118) Google Scholar In stage III CKD, clinically detectable disturbances in mineral metabolism are subtle. For example, serum parathyroid hormone levels tend to be only modestly elevated and serum phosphorous levels are generally preserved.28.Levin A. Bakris G.L. Molitch M. et al.Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease.Kid
Referência(s)