Relevance of ultrasound detection and assessment of vascular calcifications in chronic kidney disease
DOI:
https://doi.org/10.62486/agmu202477Keywords:
Vascular calcification, chronic kidney disease, ultrasound, cardiovascular risk, systematic reviewAbstract
Introduction: Chronic kidney disease (CKD) affects approximately 10% of the Spanish population and constitutes an independent cardiovascular risk factor. Vascular calcifications, especially in the abdominal aorta, are significantly associated with increased cardiovascular mortality in patients with CKD. This systematic review evaluates the evidence on the usefulness of ultrasound to detect and assess vascular calcifications in patients with CKD, and its relevance as a cardiovascular risk factor.
Methods: A systematic search of multiple electronic databases was conducted until July 2024. Original studies published between 2000 and 2024 evaluating the use of ultrasound to detect vascular calcifications in adult patients with CKD at any stage were included. Reviews, letters, editorials, animal studies and those not published in English or Spanish were excluded. Methodological quality was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane tool for clinical trials.
Results: Twenty-eight studies were included with a total of 50 to 3,000 participants per study. Most were observational studies, with 3 randomised clinical trials. Ultrasound showed good correlation with computed tomography (r=0.65-0.82) to quantify aortic and femoral calcifications. The presence of aortic calcifications was associated with increased risk of cardiovascular mortality (HR 1.8-3.2) in patients with advanced CKD and on haemodialysis. Iliac/femoral calcifications were associated with increased risk of cardiovascular events (RR 1.6-2.4) in patients with stage 3-5 CKD. Incorporation of ultrasound assessment of calcifications into CKD-specific risk algorithms significantly improved their predictive performance.
Discussion: Ultrasonography emerges as a valuable tool for the detection of vascular calcifications due to its non-invasive nature, low cost and ability to perform repeated assessments. However, limitations such as heterogeneity in assessment methods, variable sample sizes and lack of long-term follow-up in some studies were identified. Further research is needed to standardise protocols and assess the long-term impact of interventions based on ultrasound detection of calcifications.
Conclusions: Ultrasonography is an effective and accessible tool for detecting and assessing vascular calcifications in patients with CKD, providing relevant prognostic information for cardiovascular risk stratification. Its consideration as a first-line tool in nephrological practice is recommended. However, large-scale prospective studies are needed to definitively validate its prognostic value in different stages of CKD and to evaluate the efficacy of early interventions based on these findings.
References
Martínez-Castelao A, Górriz JL, Bover J, Segura-de la Morena J, Cebollada J, Escalada J, et al. Documento de consenso para la detección y manejo de la enfermedad renal crónica. Semergen [Internet]. 2014;40(8):441–59. Disponible en: http://dx.doi.org/10.1016/j.semerg.2014.09.001 DOI: https://doi.org/10.1016/j.semerg.2014.09.001
Otero Gonzáles A, de Francisco A, Gayoso P, García F, on behalf of the EPIRCE Study Group. Prevalencia de la insuficiencia renal crónica en España: Resultados del estudio EPIRCE. Nefrología [Internet]. 2010;30:78–86. Disponible en: https://www.revistanefrologia.com/es-prevalencia-insuficiencia-renal-cronica-espana-articulo-X0211699510033780
OPS. La carga de enfermedades renales en la Región de las Américas, 2000-2019 [Internet]. Portal de Datos ENLACE, Organización Panamericana de la Salud. 2021. Disponible en: https://www.paho.org/es/enlace/carga-enfermedes-renales
Rivera D. Sin trasplantes en Tarija, cada 2 meses muere un enfermo renal. Periódico digital El País [Internet]. el 2 de julio de 2020; Disponible en: https://elpais.bo/tarija/20200207_sin-trasplantes-en-tarija-cada-2-meses-muere-un-enfermo-renal.html
Okuno S, Ishimura E, Kitatani K, Fujino Y, Kohno K, Maeno Y, et al. Presence of abdominal aortic calcification is significantly associated with all-cause and cardiovascular mortality in maintenance hemodialysis patients. Am J Kidney Dis [Internet]. 2007;49(3):417–25. Available at: http://dx.doi.org/10.1053/j.ajkd.2006.12.017 DOI: https://doi.org/10.1053/j.ajkd.2006.12.017
Ma D, Yan H, Yang X, Yu Z, Ni Z, Fang W. Abdominal aortic calcification score as a predictor of clinical outcome in peritoneal dialysis patients: a prospective cohort study. BMC Nephrol [Internet]. 2020;21(1):151. Available at: http://dx.doi.org/10.1186/s12882-020-01822-9 DOI: https://doi.org/10.1186/s12882-020-01822-9
Ohya M, Otani H, Kimura K, Saika Y, Fujii R, Yukawa S, et al. Vascular calcification estimated by aortic calcification area index is a significant predictive parameter of cardiovascular mortality in hemodialysis patients. Clin Exp Nephrol [Internet]. 2011;15(6):877–83. Available at: http://dx.doi.org/10.1007/s10157-011-0517-y DOI: https://doi.org/10.1007/s10157-011-0517-y
Guérin AP, London GM, Marchais SJ, Metivier F. Arterial stiffening and vascular calcifications in end‐stage renal disease. Nephrol Dial Transplant [Internet]. 2000;15(7):1014–21. Available at: http://dx.doi.org/10.1093/ndt/15.7.1014 DOI: https://doi.org/10.1093/ndt/15.7.1014
Auza-Santivañez JC, Vitón-Castillo AA, Luperón Loforte D, Viruez-Soto JA. Ecocardiografía una herramienta valiosa en la formación del especialista en Medicina Intensiva y Emergencias. Rev. cuba. cardiol. cir. cardiovasc. [Internet]. 2021 [citado 6 Ago 2024];27(2). Disponible en: https://revcardiologia.sld.cu/index.php/revcardiologia/article/view/1138
Coll B, Betriu A, Martínez-Alonso M, Amoedo ML, Arcidiacono MV, Borras M, et al. Large artery calcification on dialysis patients is located in the intima and related to atherosclerosis. Clin J Am Soc Nephrol [Internet]. 2011;6(2):303–10. Available at: http://dx.doi.org/10.2215/cjn.04290510
Ohya M, Otani H, Kimura K, Saika Y, Fujii R, Yukawa S, et al. Improved assessment of aortic calcification in Japanese patients undergoing maintenance hemodialysis. Intern Med [Internet]. 2010;49(19):2071–5. Available at: http://dx.doi.org/10.2169/internalmedicine.49.3752 DOI: https://doi.org/10.2169/internalmedicine.49.3752
Amann K. Media calcification and intima calcification are distinct entities in chronic kidney disease. Clin J Am Soc Nephrol [Internet]. 2008;3(6):1599–605. Available at: http://dx.doi.org/10.2215/cjn.02120508 DOI: https://doi.org/10.2215/CJN.02120508
Disthabanchong S, Vipattawat K, Phakdeekitcharoen B, Kitiyakara C, Sumethkul V. Abdominal aorta and pelvic artery calcifications on plain radiographs may predict mortality in chronic kidney disease, hemodialysis and renal transplantation. Int Urol Nephrol [Internet]. 2018;50(2):355–64. Available at: http://dx.doi.org/10.1007/s11255-017-1758-9
Bessueille L, Magne D. Inflammation: a culprit for vascular calcification in atherosclerosis and diabetes. Cell Mol Life Sci. 2015 Jul;72(13):2475-89. doi: 10.1007/s00018-015-1876-4. Epub 2015 Mar 8. PMID: 25746430. Disponible en: https://pubmed.ncbi.nlm.nih.gov/25746430/ DOI: https://doi.org/10.1007/s00018-015-1876-4
Lau WL, Liu S, Vaziri ND. Chronic kidney disease results in deficiency of ABCC6, the novel inhibitor of vascular calcification. Am J Nephrol [Internet]. 2014;40(1):51–5. Available at: http://dx.doi.org/10.1159/000365014 DOI: https://doi.org/10.1159/000365014
Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, et al. Estándares SEA 2022 para el control global del riesgo cardiovascular. Clin Investig Arterioscler [Internet]. 2022;34(3):130–79. Available at: http://dx.doi.org/10.1016/j.arteri.2021.11.003
Omata M, Fukagawa M, Kakuta T. Vascular Calcification - Pathological Mechanism and Clinical Application - . Vascular calcification in chronic kidney disease-mineral and bone disorder (CKD-MBD). Clin Calcium [Internet]. 2015;25(5):645–53. Available at: http://dx.doi.org/CliCa1505645653
Tsai CH, Lin LY, Lin YH, Tsai IJ, Huang JW. Abdominal aorta calcification predicts cardiovascular but not non-cardiovascular outcome in patients receiving peritoneal dialysis: A prospective cohort study. Medicine (Baltimore). 2020 Sep 11;99(37):e21730. doi: 10.1097/MD.0000000000021730. PMID: 32925715; PMCID: PMC7489593. Disponible en: https://pubmed.ncbi.nlm.nih.gov/32925715/ DOI: https://doi.org/10.1097/MD.0000000000021730
Organización Mundial de la Salud. Temas de salud [Internet]. [citado el 29 de julio de 2024]. Disponible en: https://www.who.int/es/health-topics
Marín Prada M del C, Condori-Villca N, Gutiérrez Garcia F, Rodriguez García CA, Martínez Morales M Ángel, Auza-Santiváñez JC, Aguilar-Medrano F. Chronic kidney disease and its risk stratification in Cuba. Data and Metadata [Internet]. 2023 Jun. 12 [cited 2024 Aug. 6];2:49. Available from: https://dm.saludcyt.ar/index.php/dm/article/view/49 DOI: https://doi.org/10.56294/dm202349
Márquez Molina J, Auza-Santivañez JC, Cruz-Choquetopa E, Antezana-Muñoz JB, Arteaga Iriarte O, Fernández-Burgoa H. Early prediction of acute kidney injury in neurocritical patients: relevance of renal resistance index and intrarenal venous Doppler as diagnostic tools. Data and Metadata [Internet]. 2023 Apr. 9 [cited 2024 Aug. 6];2:30. Available from: https://dm.saludcyt.ar/index.php/dm/article/view/30 DOI: https://doi.org/10.56294/dm202330
Bank AJ, Wang H, Holte JE, Mullen K, Shammas R, Kubo SH. Contribution of collagen, elastin, and smooth muscle to in vivo human brachial artery wall stress and elastic modulus. Circulation [Internet]. 1996;94(12):3263–70. Available at: http://dx.doi.org/10.1161/01.cir.94.12.3263 DOI: https://doi.org/10.1161/01.CIR.94.12.3263
Disthabanchong S, Vipattawat K, Phakdeekitcharoen B, Kitiyakara C, Sumethkul V. Abdominal aorta and pelvic artery calcifications on plain radiographs may predict mortality in chronic kidney disease, hemodialysis and renal transplantation. Int Urol Nephrol [Internet]. 2018;50(2):355–64. Available at: http://dx.doi.org/10.1007/s11255-017-1758-9 DOI: https://doi.org/10.1007/s11255-017-1758-9
Coll B, Betriu A, Martínez-Alonso M, Amoedo ML, Arcidiacono MV, Borras M, Valdivielso JM, Fernández E. Large artery calcification on dialysis patients is located in the intima and related to atherosclerosis. Clin J Am Soc Nephrol [Internet]. 2011;6(2):303–10. Disponible en: http://dx.doi.org/10.2215/cjn.04290510 DOI: https://doi.org/10.2215/CJN.04290510
Gepner AD, Young R, Delaney JA, Budoff MJ, Polak JF, Blaha MJ, et al. Comparison of carotid plaque score and coronary artery calcium score for predicting cardiovascular disease events: The multi‐ethnic study of atherosclerosis. J Am Heart Assoc [Internet]. 2017;6(2). Available at: http://dx.doi.org/10.1161/jaha.116.005179
Hecht HS, Cronin P, Blaha MJ, Budoff MJ, Kazerooni EA, Narula J, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr [Internet]. 2017;11(1):74–84. Available at: http://dx.doi.org/10.1016/j.jcct.2016.11.003 DOI: https://doi.org/10.1016/j.jcct.2016.11.003
Mostaza JM, Pintó X, Armario P, Masana L, Real JT, Valdivielso P, et al. Estándares SEA 2022 para el control global del riesgo cardiovascular. Clin Investig Arterioscler [Internet]. 2022;34(3):130–79. Available at: http://dx.doi.org/10.1016/j.arteri.2021.11.003 DOI: https://doi.org/10.1016/j.arteri.2021.11.003
Organización Mundial de la Salud (OMS). Enfermedades cardiovasculares. Temas de Salud [Internet]. [citado el 29 de julio de 2024]. Disponible en: https://www.who.int/es/health-topics/cardiovascular-diseases
Omata M, Fukagawa M, Kakuta T. Vascular Calcification - Pathological Mechanism and Clinical Application - . Vascular calcification in chronic kidney disease-mineral and bone disorder (CKD-MBD). Clin Calcium [Internet]. 2015;25(5):645–53. Available at: http://dx.doi.org/CliCa1505645653
Bover J, Evenepoel P, Urena-Torres P, Vervloet MG, Brandenburg V, Mazzaferro S, et al. Pro: Cardiovascular calcifications are clinically relevant. Nephrol Dial Transplant [Internet]. 2015;30(3):345–51. Available at: http://dx.doi.org/10.1093/ndt/gfv020
Gepner AD, Young R, Delaney JA, Budoff MJ, Polak JF, Blaha MJ, et al. Comparison of carotid plaque score and coronary artery calcium score for predicting cardiovascular disease events: The multi‐ethnic study of atherosclerosis. J Am Heart Assoc [Internet]. 2017;6(2). Available at: http://dx.doi.org/10.1161/jaha.116.005179 DOI: https://doi.org/10.1161/JAHA.116.005179
Cho I, Ó Hartaigh B, Gransar H, Valenti V, Lin FY, Achenbach S, et al. Prognostic implications of coronary artery calcium in the absence of coronary artery luminal narrowing. Atherosclerosis [Internet]. 2017;262:185–90. Available at: http://dx.doi.org/10.1016/j.atherosclerosis.2016.12.006 DOI: https://doi.org/10.1016/j.atherosclerosis.2016.12.006
Tamayo-Roca C, Roca-Revilla M, Nápoles-Quiñones G. La modelación científica: algunas consideraciones teórico-metodológicas. Santiago [Internet]. 2017;(142):79–90. Disponible en: https://santiago.uo.edu.cu/index.php/stgo/article/view/2123
Monje Alvarez CA. Metodologia de la Investigación Cualitativa y Cuantitativa - Guia Didactica. Neiva, Colombia: Universidad Surcolombiana; 2011.
Bover J, Evenepoel P, Urena-Torres P, Vervloet MG, Brandenburg V, Mazzaferro S, et al. Pro: Cardiovascular calcifications are clinically relevant. Nephrol Dial Transplant [Internet]. 2015;30(3):345–51. Available at: http://dx.doi.org/10.1093/ndt/gfv020 DOI: https://doi.org/10.1093/ndt/gfv020
Canal C, Pellicer R, Rocha CI, Calero F, Gracia S, Montañés R, Ballarín J, Bover J. Tables estimating glomerular filtration rate from plasma creatinine. Nefrologia [Internet]. 2008;28(3):317-24. Available at: https://pubmed.ncbi.nlm.nih.gov/18590499/
Kim ED, Parekh RS. Calcium and sudden cardiac death in end‐stage renal disease. Semin Dial [Internet]. 2015;28(6):624–35. Disponible en: http://dx.doi.org/10.1111/sdi.12419 DOI: https://doi.org/10.1111/sdi.12419
Published
Issue
Section
License
Copyright (c) 2024 Jhossmar Cristians Auza-Santivañez, Blas Apaza-Huanca, Jose Luis Diaz-Guerrero, Daniel Ramiro Elías Vallejos-Rejas, Yenifer Zelaya-Espinoza, Ismael Vargas-Gallego, Ariel Sosa Remón (Author)

This work is licensed under a Creative Commons Attribution 4.0 International License.
The article is distributed under the Creative Commons Attribution 4.0 License. Unless otherwise stated, associated published material is distributed under the same licence.