Abstract
Background: Coronary artery calcification (CAC) is common in patients with chronic kidney disease on hemodialysis (CKD-5D) and is an important predictor of mortality. However, cardiac functional links between CAC and mortality have not been well established. This study tested the hypothesis that CAC increases mortality by adversely affecting cardiac function. Methods: Patients were recruited from 37 regional dialysis centers. 2-D and Doppler echocardiographic analyses were performed, and CAC was measured using 64-slice computed tomography. Relationships between CAC and echocardiographic measures of left ventricular (LV) function were analyzed. Survival was assessed with median follow-up of 37 months. Results: There were 157 patients: 59% male, 46% Caucasian, 48% diabetic. Median age was 55 years, and median duration of CKD-5D was 45 months. Agatston CAC scores > 100 were found in 69% of patients, with 51% having a score > 400. CAC was associated with measures of LV systolic and diastolic function (global longitudinal strain (GLS; rho = 0.270, p = 0.004)), peak LV systolic velocity (rho = –0.259, p = 0.004), and estimate of LV filling pressure (E:E’; rho = 0.286, p = 0.001). Multivariate regression confirmed these relationships after adjustment for age, gender, LV ejection fraction, and coronary artery disease. Valvular calcification varied linearly with CAC (p < 0.05). Both LV diastolic and systolic functional measures were significant predictors of mortality, the strongest of which was LV diastolic dysfunction. Conclusions: These findings show a link between CAC, cardiac function, and mortality in CKD-5D. LV diastolic function (E:E’), peak LV systolic velocity, and GLS are independent predictors of mortality. Valvular calcification may be an important marker of CAC in CKD-5D. These effects on cardiac function likely explain the high mortality with CKD-5D and describe a potentially-valuable role for echocardiography in the routine management of these patients.
Highlights
Patients with chronic kidney disease (CKD) are at increased risk of developing cardiovascular (CV) disease and have a higher mortality attributed to cardiac causes compared to patients without CKD [1, 2, 3]
Cardiac valvular calcification detected by echocardiography is common in CKD-5D and is linked to both CAC severity and abnormal left ventricular (LV) function
While 26% of these patients reported a history of CAD, 83% were found to have evidence of CAC, and more than half had a CAC score above 400, which has been associated with an elevated risk of future CV events including myocardial infarction and death
Summary
Patients with chronic kidney disease (CKD) are at increased risk of developing cardiovascular (CV) disease and have a higher mortality attributed to cardiac causes compared to patients without CKD [1, 2, 3]. By the time patients with CKD develop end-stage renal disease and are in need of dialysis, many will have 1) evidence of coronary artery calcification (CAC), 2) structural cardiac abnormalities, and 3) abnormal cardiac diastolic function [4, 5, 6, 7, 8, 9, 10, 11]. CAC was associated with measures of LV systolic and diastolic function (global longitudinal strain (GLS; rho = 0.270, p = 0.004)), peak LV systolic velocity (rho = –0.259, p = 0.004), and estimate of LV filling pressure (E:E’; rho = 0.286, p = 0.001) Multivariate regression confirmed these relationships after adjustment for age, gender, LV ejection fraction, and coronary artery disease. These effects on cardiac function likely explain the high mortality with CKD-5D and describe a potentially-valuable role for echocardiography in the routine management of these patients
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