Coronary-Artery Calcification in Young Adults with End-Stage Renal Disease Who Are Undergoing Dialysis
William G. Goodman, M.D., Jonathan Goldin, M.D., Ph.D., Beatriz D. Kuizon, M.D., Chun Yoon, M.D., Ph.D., Barbara Gales, R.N., Donna Sider, R.N., Yan Wang, Ph.D., Joanie Chung, M.S., Aletha Emerick, Lloyd Greaser, M.P.H., Robert M. Elashoff, Ph.D., and Isidro B. Salusky, M.D.
Background Cardiovascular disease is common in older adultswith end-stage renal disease who are undergoing regular dialysis,but little is known about the prevalence and extent of cardiovasculardisease in children and young adults with end-stage renal disease.
Methods We used electron-beam computed tomography (CT) to screenfor coronary-artery calcification in 39 young patients withend-stage renal disease who were undergoing dialysis (mean [±SD]age, 19±7 years; range, 7 to 30) and 60 normal subjects20 to 30 years of age. In those with evidence of calcificationon CT scanning, we determined its extent. The results were correlatedwith the patients' clinical characteristics, serum calcium andphosphorus concentrations, and other biochemical variables.
Results None of the 23 patients who were younger than 20 yearsof age had evidence of coronary-artery calcification, but itwas present in 14 of the 16 patients who were 20 to 30 yearsold. Among those with calcification, the mean calcificationscore was 1157± 1996, and the median score was 297. Bycontrast, only 3 of the 60 normal subjects had calcification.As compared with the patients without coronary-artery calcification,those with calcification were older (26±3 vs. 15±5years, P<0.001) and had been undergoing dialysis for a longerperiod (14±5 vs. 4±4 years, P< 0.001). Themean serum phosphorus concentration, the mean calcium–phosphorusion product in serum, and the daily intake of calcium were higheramong the patients with coronary-artery calcification. Among10 patients with calcification who underwent follow-up CT scanning,the calcification score nearly doubled (from 125±104to 249±216, P=0.02) over a mean period of 20±3months.
Conclusions Coronary-artery calcification is common and progressivein young adults with end-stage renal disease who are undergoingdialysis.
The life span of adults with end-stage renal disease is reduced,and cardiovascular disease accounts for approximately half thedeaths among adults undergoing regular dialysis.1,2 Contributingfactors include hypertension, glucose intolerance, dyslipidemia,high serum homocysteine concentrations, and abnormalities incalcium and phosphorus metabolism.3,4,5,6,7,8,9 Many of thesame disturbances are present in children and young adults withend-stage renal disease, but little is known about the prevalenceor extent of cardiovascular disease in these patients.
The presence and progression of calcified coronary-artery lesionscan be determined by electron-beam computed tomography (CT).10,11,12,13The prevalence of coronary-artery calcification increases withage in both men and women, and the extent of calcification,as measured by electron-beam CT, is correlated with the extentand severity of angiographically documented atheroscleroticlesions.13,14,15 Therefore, electron-beam CT may be a usefulnoninvasive method of screening among patients at risk for coronaryartery disease.
Braun et al. noted that coronary-artery calcification was muchmore common among adult patients with end-stage renal diseasewho were undergoing hemodialysis than among normal subjectsof the same age and sex.16 Whether similar changes occur inyounger patients on dialysis is not known. Few assessments ofcoronary-artery calcification have been performed in patientsof either sex who are younger than 30 years of age, and thereis no information about the prevalence of coronary-artery calcificationin children or young adults with end-stage renal disease. Weundertook this study to determine the prevalence and extentof coronary-artery calcification in children, adolescents, andadults who were 30 years of age or younger, who had end-stagerenal disease, and who were undergoing regular dialysis.
Methods
Study Subjects
All 66 patients who were 30 years of age or younger and whowere undergoing regular dialysis in the UCLA Adult and PediatricDialysis Program were invited to participate in the study. Thirty-ninepatients agreed to enroll; 23 were younger than 20 years old,and 16 were 20 to 30 years old. Twenty-one patients were treatedwith continuous cycling peritoneal dialysis, and 18 patientswith thrice-weekly hemodialysis.
The causes of renal failure in the 39 patients included glomerulonephritisin 9, Alport's syndrome in 6, renal dysplasia in 7, obstructiveuropathy in 3, vasculitis in 3, reflux nephropathy in 2, andpolycystic kidney disease, diabetes mellitus, and tuberous sclerosisin 1 each. The cause of renal failure was unknown in six patients.The clinical characteristics and causes of renal failure didnot differ significantly between the patients treated with hemodialysisand those treated by peritoneal dialysis.
Screening for coronary-artery calcification was performed withelectron-beam CT. The measurements were repeated in 22 patientsafter 18 to 24 months. The results of monthly serum biochemicaldeterminations were collected for the six months immediatelypreceding each scan in each patient, and these results wereaveraged to obtain a mean value for each measurement. They includedmeasurements of serum calcium, phosphorus, alkaline phosphatase,cholesterol, and albumin and calculations of the serum calcium–phosphorusion product.17,18 Serum parathyroid hormone was measured eithermonthly in patients treated with calcitriol or quarterly inthose not receiving calcitriol.17,18 We also obtained electron-beamCT scans of 32 women and 28 men between the ages of 20 and 30years who had no known history of cardiovascular or renal disease.
Height, weight, and body-mass index (the weight in kilogramsdivided by the square of the height in meters) were measuredwhen the scans were done. Information about primary causes ofrenal failure, systolic and diastolic blood pressure, the durationof chronic renal disease, the duration of treatment with dialysis(excluding, in the case of 27 patients, the intervals of adequaterenal function as a result of renal transplantation), previousparathyroidectomy, and the use of calcitriol therapy was alsogathered. The cumulative doses of calcium-containing medicationsand calcitriol during the six months immediately preceding thescans were calculated for each patient.
The study protocol was approved by the UCLA Human-Subjects ProtectionCommittee. All study subjects, or a parent or guardian in thecase of those who were younger than 18 years of age, gave writteninformed consent.
Protocol for Electron-Beam CT
All imaging procedures were performed with the same scanner(Evolution XP-150, Imatron, South San Francisco, Calif.).19Contiguous transverse imaging sections were obtained with theuse of 3-mm collimation, starting approximately 2 cm below thecarina and extending to the inferior margin of the heart. Imagesfor each section were acquired with the use of a single sliceduring a 100-msec exposure while the subject held his or herbreath. The timing of image acquisition was coordinated withthe diastolic phase of the cardiac cycle at 80 percent of theRR interval with the use of electrocardiographic monitoring.Images were reconstructed with the use of a 260-mm or 300-mmfield of view, a matrix of 512 by 512, and a sharp reconstructionfilter.
All scans were scored with the use of Imatron software (version12.25) by one of two technicians who had no knowledge of theclinical condition of the subjects being evaluated or the resultsof previous scans. Regions of interest were identified aroundfoci of calcification within epicardial arteries, as definedby the presence of two contiguous pixels with density valuesof at least 130 Hounsfield units. As originally described byAgatston et al.,19 the degree of coronary-artery calcificationwas then calculated by multiplying the area of each calcifiedlesion by a weighting factor corresponding to the peak pixelintensity for each lesion to yield a lesion-specific calcificationscore. The sum of the scores for all arterial lesions providesan overall score for each subject.19 All images were reviewedby one of the radiologists most familiar with the method ofdetermining these scores at our institution.
Statistical Analysis
The results are presented as means ±SD. The distributionof categorical variables among the groups was assessed by chi-squareanalysis or by Fisher's exact test.20,21 Comparisons betweengroups were made with use of unpaired t-tests, and the rank-sumtest was used for data that were normally distributed.20,21Paired t-tests were used to assess changes in coronary-arterycalcification scores over time.20
Results
The mean age of the 39 patients with end-stage renal diseasewho underwent screening for coronary-artery calcification was19±7 years (range, 7 to 30). There were 20 female patientsand 19 male patients. Four patients were black, 6 were white,5 were Asian, and 24 were Hispanic. The mean duration of dialysiswas 7±6 years (range, 0.3 to 21). Among the 23 patientswho were younger than 20 years of age, none had evidence ofcoronary-artery calcification. In contrast, 14 of the 16 patients(7 women and 7 men) who were 20 to 30 years of age had evidenceof coronary-artery calcification on CT scanning (Figure 1).Their calcification scores averaged 1157±1996 (range,2 to 7047; median, 297). By comparison, coronary-artery calcificationwas found in only 3 of the 60 normal subjects, who were 20 to30 years old. Two women (age, 24 and 28 years) had calcificationscores of 2 and 1, and one 29-year-old man had a score of 77.
Figure 1. Coronary-Artery Calcification Scores in 39 Children and Young Adults with End-Stage Renal Disease Who Were Treated by Dialysis, According to Age.
Coronary-artery calcification was assessed by electron-beam computed tomography. The scale on the y axis is logarithmic.
The patients with end-stage renal disease did not differ significantlyfrom the normal subjects with respect to sex or racial or ethnicgroup, but the normal subjects were older (mean age, 26±4vs. 19±7 years; P<0.001). Matching of patients andnormal subjects according to sex, age (within two years), andbody-mass index (within 10 percent) yielded 11 patients and27 normal subjects, of whom 9 (82 percent) and 2 (7 percent),respectively, had coronary-artery calcification (P<0.001).
The patients with coronary-artery calcification did not differsignificantly from those without calcification with respectto systolic and diastolic blood pressure, and the proportionof males in each group was similar (Table 1). Only one patienthad diabetes mellitus, and his calcification score was zero.On average, the patients with calcification were older, however,and they had been undergoing dialysis longer. The median durationof dialysis was 13 years in the patients with coronary-arterycalcification and 2 years in those without calcification. Therefore,the probability of calcification increased as a function ofthe duration of dialysis (Figure 2).
Figure 2. Prevalence of Coronary-Artery Calcification among 39 Patients with End-Stage Renal Disease, According to the Duration of Treatment with Dialysis.
Coronary-artery calcification was assessed by electron-beam computed tomography. The stepped dashed line indicates the proportion of patients with evidence of coronary-artery calcification within each interval of approximately four years. The curved line reflects estimates derived by logistic-regression analysis. All patients were 30 years of age or younger when they were first evaluated by electron-beam computed tomography. The duration of dialysis excludes intervals of adequate renal function as a result of renal transplantation in 27 patients.
Serum phosphorus concentrations tended to be higher and thecalcium–phosphorus ion product in serum was significantlyhigher in the patients with coronary-artery calcification thanin those without calcification (Table 1). Serum alkaline phosphataseconcentrations were lower in those with coronary-artery calcification,whereas the serum calcium and parathyroid hormone concentrationsdid not differ significantly between the two groups. The amountof calcium ingested daily as a phosphate-binding agent was nearlytwice as great in the patients with coronary-artery calcificationas in those without calcification (6456±4278 vs. 3325±1490mg per day, P=0.02).
The proportion of patients who were undergoing peritoneal dialysisor who were receiving calcitriol did not differ significantlybetween those with coronary-artery calcification and those withoutcalcification. Thirteen of the 27 patients who had undergonea kidney transplantation had coronary-artery calcification,whereas only 1 of 12 patients who had not undergone transplantationhad calcification (P= 0.03). This difference was attributable,however, to the longer duration of dialysis in patients whohad undergone transplantation, as compared with those who hadnot (9±7 vs. 3±3 years, P<0.001).
The proportion of patients who had undergone parathyroidectomyalso did not differ significantly between those with coronary-arterycalcification and those without calcification, but 6 of the9 patients who had undergone parathyroidectomy (67 percent)had calcification, as compared with 8 of 30 patients who hadnot (27 percent; P=0.05). Again, these patients were older,on average, and they had been undergoing dialysis longer. Theserum concentrations of calcium and phosphorus and the serumcalcium–phosphorus ion product were higher in the patientswho had undergone parathyroidectomy (data not shown).
None of the patients with coronary-artery calcification hadsymptoms of angina or a history of myocardial infarction, butsix had electrocardiographic abnormalities, even after the exclusionof changes that were likely to be due to hypertension or anexcess of extracellular fluid. The abnormalities were ischemicchanges in five and first-degree atrioventricular block in one.Mitral-valve calcification was detected in two of the sevenpatients who were examined by echocardiography. One of thesepatients subsequently underwent mitral-valve and aortic-valvereplacement, and a calcified atheroma near the ostium of theright coronary artery was detected by echocardiography in theother.
CT scanning was repeated in 22 patients a mean of 22±7months later. Among 12 patients who had no evidence of coronary-arterycalcification on the initial scan, 2 had evidence of calcificationon follow-up scanning. Among the 10 of these 22 patients whohad evidence of coronary-artery calcification on the initialscan, 9 had a higher calcification score on follow-up scanning;the values nearly doubled (from 125±104 to 249±216)over a mean period of 20±3 months (P=0.02) (Figure 3).Serum concentrations of phosphorus and the calcium–phosphorusion product were positively correlated with the change in calcificationscores at follow-up.
Figure 3. Coronary-Artery Calcification Scores in 10 Patients with Evidence of Coronary-Artery Calcification on the Initial Scan and in 2 Patients in Whom Calcification Was Detected during Follow-up.
Coronary-artery calcification was assessed by electron-beam computed tomography. The mean interval between the scans was 20 months (range, 12 to 41). All patients underwent regular dialysis, and all were 20 to 30 years of age at the time of the first scan.
Discussion
Our results indicate that coronary-artery calcification, asmeasured by electron-beam CT, is common in women and men whoare 30 years old or younger and who have end-stage renal diseasefor which they are undergoing regular dialysis. It is quiteuncommon, however, in normal subjects who are 20 to 30 yearsof age. Indeed, only 10 percent of women and 25 percent of menbetween the ages of 40 and 49 years who have normal renal functionhave coronary-artery calcification,19 whereas in our study,seven of eight women (88 percent) and seven of eight men (88percent) who were 20 to 30 years of age had calcification. Thus,coronary-artery calcification occurs more frequently in youngadults with end-stage renal disease than in either normal subjectsof the same age and sex or older adults with normal renal function.
Several established risk factors for coronary artery disease,such as elevated levels of systolic and diastolic blood pressure,male sex, and the presence of diabetes mellitus, were not associatedwith coronary-artery calcification in this relatively smallstudy of young patients who were undergoing dialysis. Only onepatient had diabetes, reflecting the low prevalence of diabetesamong young adults who are undergoing dialysis.22 Among thosewith coronary-artery calcification, serum cholesterol concentrationswere lower and serum albumin concentrations and body-mass indexwere higher than in the patients without calcification. Thesefindings do not support the view that malnutrition has a rolein the development of coronary artery disease in young personstreated with dialysis, as has been suggested in the case ofolder adults.23
The duration of treatment with dialysis was substantially longer,however, in the patients with coronary-artery calcificationthan in those without calcification. All had undergone regulardialysis for at least five years, and most started dialysisas children or adolescents. Indeed, the age at which dialysiswas started averaged 13±4 years among those with coronary-arterycalcification.
The relation between coronary-artery calcification scores andclinically important coronary-artery lesions is controversial.24In persons older than 50 years of age, calcification scoresof more than 10 but less than 100 are considered to reflectthe presence of minimal or mild luminal stenosis.19 Values of100 to 400 suggest the presence of nonobstructive coronary arterydisease, but stenotic lesions are found in some patients whohave scores within this range.19 The calcification scores rangedfrom 2 to 7047 in our patients, and values exceeded 100 in 11of them. These findings indicate that many young adults withend-stage renal disease have radiographic evidence of clinicallysilent yet potentially serious coronary-artery lesions, andsome have electrocardiographic and echocardiographic abnormalities.Further work will be required to determine whether the previouslydescribed relation between the presence of coronary-artery calcificationand angiographically documented coronary-artery lesions in thegeneral population applies to patients with end-stage renaldisease.
When coronary-artery calcification was initially present, thedegree of calcification increased during follow-up, and themean calcification score nearly doubled in less than two years.The magnitude of change was greater than that reported previouslyin middle-aged adults, in whom the scores rose 24 percent peryear.25 Thus, the rate of progression of coronary-artery calcificationin young adults treated with dialysis exceeds the rate of progressionin older persons with normal renal function.
The mechanisms responsible for vascular calcification in patientswith chronic renal failure remain uncertain, and the relationbetween arterial-wall calcification and the atheroscleroticprocess is not fully understood.26 Calcium deposits are found,however, in a large proportion of atherosclerotic lesions, providingthe basis for the use of electron-beam CT to screen for coronaryartery disease.24,27 The presence of coronary-artery calcificationin young adult patients who are undergoing dialysis may thereforesimply reflect the high prevalence of atherosclerosis documentedpreviously among those with end-stage renal disease.28,29
It is possible, however, that alterations in mineral metabolismand the treatment of these abnormalities contribute to the developmentof vascular calcification in patients with end-stage renal disease.30Treatment with vitamin D has been associated with postmortemevidence of vascular and soft-tissue calcification in childrenwith chronic renal failure.31 On the basis of data from theU.S. Renal Data System, high serum phosphorus concentrationsand high values for the calcium–phosphorus ion productin serum were independent risk factors for death in patientswith end-stage renal disease.9 Whether these factors, actingalone or in combination, directly influence the process of calciumdeposition in the arterial wall remains to be determined, butan inverse relation between the serum calcitriol concentrationsand the degree of coronary-artery calcification has been reportedin subjects with normal renal function.32
Our results provide support for the concept that disturbancesin mineral metabolism contribute to coronary-artery calcificationin patients with end-stage renal disease. Patients with calcificationhad higher serum phosphorus concentrations and a higher calcium–phosphorusion product in serum, and their daily intake of calcium-containingphosphate-binding agents was nearly twice as great as in thosewithout calcification. Thus, long-term exposure to the abnormalitiesin mineral metabolism that characterize chronic renal failureand the treatment of these abnormalities appear to contributeto the development of coronary-artery calcification in youngadults with end-stage renal disease.
Additional studies are needed to determine whether the use oflarge oral doses of calcium-containing phosphate-binding agentsor the treatment of secondary hyperparathyroidism with vitaminD sterols promotes arterial-wall calcification in patients withend-stage renal disease. The adverse cardiovascular implicationsof coronary-artery calcification in patients with end-stagerenal disease who are treated by long-term dialysis underscorethe need to expedite renal transplantation in those in whomend-stage renal disease develops in childhood or adolescence.33Clinicians should be aware, however, that young adults undergoingregular dialysis may harbor clinically silent yet potentiallyserious coronary artery disease that is disproportionate totheir age.
Supported in part by grants from the Public Health Service (DK-52905,DK-35423, and RR-00865) and by funds from the Casey Lee BallFoundation.
Source Information
From the Departments of Medicine (W.G.G., D.S.), Radiological Sciences (J.G., C.Y., A.E., L.G.), Pediatrics (B.D.K., B.G., I.B.S.), and Biomathematics (Y.W., J.C., R.M.E.), UCLA School of Medicine, Los Angeles.
Address reprint requests to Dr. Goodman at the Division of Nephrology, 7-155 Factor Bldg., UCLA Medical Center, 10833 Le Conte Ave., Los Angeles, CA 90095, or at wgoodman{at}ucla.edu.
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Urbina, E. M., Williams, R. V., Alpert, B. S., Collins, R. T., Daniels, S. R., Hayman, L., Jacobson, M., Mahoney, L., Mietus-Snyder, M., Rocchini, A., Steinberger, J., McCrindle, B., on behalf of the American Heart Association Athero,
(2009). Noninvasive Assessment of Subclinical Atherosclerosis in Children and Adolescents: Recommendations for Standard Assessment for Clinical Research: A Scientific Statement From the American Heart Association. Hypertension
54: 919-950
[Abstract][Full Text]
Jamal, S. A., Fitchett, D., Lok, C. E., Mendelssohn, D. C., Tsuyuki, R. T.
(2009). The effects of calcium-based versus non-calcium-based phosphate binders on mortality among patients with chronic kidney disease: a meta-analysis. Nephrol Dial Transplant
24: 3168-3174
[Abstract][Full Text]
Johnson, D. W.
(2009). Sevelamer versus calcium-based phosphate binders in chronic kidney disease: what should we conclude from the evidence to date?. Nephrol Dial Transplant
24: 2970-2972
[Full Text]
Ix, J. H., Katz, R., De Boer, I. H., Kestenbaum, B. R., Allison, M. A., Siscovick, D. S., Newman, A. B., Sarnak, M. J., Shlipak, M. G., Criqui, M. H.
(2009). Association of chronic kidney disease with the spectrum of ankle brachial index the CHS (Cardiovascular Health Study).. J Am Coll Cardiol
54: 1176-1184
[Abstract][Full Text]
Eddington, H., Hurst, H., Ramli, M. T., Speake, M., Hutchison, A. J.
(2009). CALCIUM AND MAGNESIUM FLUX IN AUTOMATED PERITONEAL DIALYSIS. pdi
29: 536-541
[Abstract][Full Text]
Koivuviita, N., Tertti, R., Jarvisalo, M., Pietila, M., Hannukainen, J., Sundell, J., Nuutila, P., Knuuti, J., Metsarinne, K.
(2009). Increased basal myocardial perfusion in patients with chronic kidney disease without symptomatic coronary artery disease. Nephrol Dial Transplant
24: 2773-2779
[Abstract][Full Text]
Davidovich, E., Davidovits, M., Peretz, B., Shapira, J., Aframian, D. J.
(2009). The correlation between dental calculus and disturbed mineral metabolism in paediatric patients with chronic kidney disease. Nephrol Dial Transplant
24: 2439-2445
[Abstract][Full Text]
Hong Zhang, , Li, X.-Y., Yajun Si, , Xilie Lu, , Liping Chen, , Zhaoyang Liu,
(2009). Manifestation of lower extremity atherosclerosis in patients with high ankle-brachial index. British Journal of Diabetes & Vascular Disease
9: 160-164
[Abstract]
Parker, B. D., Ix, J. H., Cranenburg, E. C. M., Vermeer, C., Whooley, M. A., Schurgers, L. J.
(2009). Association of kidney function and uncarboxylated matrix Gla protein: Data from the Heart and Soul Study. Nephrol Dial Transplant
24: 2095-2101
[Abstract][Full Text]
Mizobuchi, M., Towler, D., Slatopolsky, E.
(2009). Vascular Calcification: The Killer of Patients with Chronic Kidney Disease. J. Am. Soc. Nephrol.
20: 1453-1464
[Abstract][Full Text]
Hage, F. G., Venkataraman, R., Zoghbi, G. J., Perry, G. J., DeMattos, A. M., Iskandrian, A. E.
(2009). The scope of coronary heart disease in patients with chronic kidney disease.. J Am Coll Cardiol
53: 2129-2140
[Abstract][Full Text]
Neven, E., Dams, G., Postnov, A., Chen, B., De Clerck, N., De Broe, M. E., D'Haese, P. C., Persy, V.
(2009). Adequate phosphate binding with lanthanum carbonate attenuates arterial calcification in chronic renal failure rats. Nephrol Dial Transplant
24: 1790-1799
[Abstract][Full Text]
Foley, R. N.
(2009). Phosphate Levels and Cardiovascular Disease in the General Population. CJASN
4: 1136-1139
[Abstract][Full Text]
Shantouf, R., Kovesdy, C. P., Kim, Y., Ahmadi, N., Luna, A., Luna, C., Rambod, M., Nissenson, A. R., Budoff, M. J., Kalantar-Zadeh, K.
(2009). Association of Serum Alkaline Phosphatase with Coronary Artery Calcification in Maintenance Hemodialysis Patients. CJASN
4: 1106-1114
[Abstract][Full Text]
Lopez, I., Mendoza, F. J., Guerrero, F., Almaden, Y., Henley, C., Aguilera-Tejero, E., Rodriguez, M.
(2009). The calcimimetic AMG 641 accelerates regression of extraosseous calcification in uremic rats. Am. J. Physiol. Renal Physiol.
296: F1376-F1385
[Abstract][Full Text]
Aikawa, E., Aikawa, M., Libby, P., Figueiredo, J.-L., Rusanescu, G., Iwamoto, Y., Fukuda, D., Kohler, R. H., Shi, G.-P., Jaffer, F. A., Weissleder, R.
(2009). Arterial and Aortic Valve Calcification Abolished by Elastolytic Cathepsin S Deficiency in Chronic Renal Disease. Circulation
119: 1785-1794
[Abstract][Full Text]
Jara, A., Chacon, C., Burgos, M. E., Droguett, A., Valdivieso, A., Ortiz, M., Troncoso, P., Mezzano, S.
(2009). Expression of gremlin, a bone morphogenetic protein antagonist,is associated with vascular calcification in uraemia. Nephrol Dial Transplant
24: 1121-1129
[Abstract][Full Text]
Jean, G., Bresson, E., Terrat, J.-C., Vanel, T., Hurot, J.-M., Lorriaux, C., Mayor, B., Chazot, C.
(2009). Peripheral vascular calcification in long-haemodialysis patients: associated factors and survival consequences. Nephrol Dial Transplant
24: 948-955
[Abstract][Full Text]
Adragao, T., Pires, A., Birne, R., Curto, J. D., Lucas, C., Goncalves, M., Negrao, A. P.
(2009). A plain X-ray vascular calcification score is associated with arterial stiffness and mortality in dialysis patients. Nephrol Dial Transplant
24: 997-1002
[Abstract][Full Text]
Tentori, F., Albert, J. M., Young, E. W., Blayney, M. J., Robinson, B. M., Pisoni, R. L., Akiba, T., Greenwood, R. N., Kimata, N., Levin, N. W., Piera, L. M., Saran, R., Wolfe, R. A., Port, F. K.
(2009). The survival advantage for haemodialysis patients taking vitamin D is questioned: findings from the Dialysis Outcomes and Practice Patterns Study. Nephrol Dial Transplant
24: 963-972
[Abstract][Full Text]
Porazko, T., Kuzniar, J., Kusztal, M., Kuzniar, T. J., Weyde, W., Kuriata-Kordek, M., Klinger, M.
(2009). IL-18 is involved in vascular injury in end-stage renal disease patients. Nephrol Dial Transplant
24: 589-596
[Abstract][Full Text]
Adragao, T., Herberth, J., Monier-Faugere, M.-C., Branscum, A. J., Ferreira, A., Frazao, J. M., Dias Curto, J., Malluche, H. H.
(2009). Low Bone Volume--A Risk Factor for Coronary Calcifications in Hemodialysis Patients. CJASN
4: 450-455
[Abstract][Full Text]
Bugnicourt, J.-M., Chillon, J.-M., Massy, Z. A, Canaple, S., Lamy, C., Deramond, H., Godefroy, O.
(2009). High Prevalence of Intracranial Artery Calcification in Stroke Patients with CKD: A Retrospective Study. CJASN
4: 284-290
[Abstract][Full Text]
McIntyre, C. W., Pai, P., Warwick, G., Wilkie, M., Toft, A. J., Hutchison, A. J.
(2009). Iron-Magnesium Hydroxycarbonate (Fermagate): A Novel Non-Calcium-Containing Phosphate Binder for the Treatment of Hyperphosphatemia in Chronic Hemodialysis Patients. CJASN
4: 401-409
[Abstract][Full Text]
Isakova, T., Gutierrez, O. M., Chang, Y., Shah, A., Tamez, H., Smith, K., Thadhani, R., Wolf, M.
(2009). Phosphorus Binders and Survival on Hemodialysis. J. Am. Soc. Nephrol.
20: 388-396
[Abstract][Full Text]
Wang, A. Y.-M.
(2009). VASCULAR AND OTHER TISSUE CALCIFICATION IN PERITONEAL DIALYSIS PATIENTS. pdi
29: S9-S14
[Abstract][Full Text]
Shroff, R.
(2009). MONITORING CARDIOVASCULAR RISK FACTORS IN CHILDREN ON DIALYSIS. pdi
29: S173-S175
[Abstract][Full Text]
Rodriguez-Garcia, M., Gomez-Alonso, C., Naves-Diaz, M., Diaz-Lopez, J. B., Diaz-Corte, C., Cannata-Andia, J. B., the Asturias Study Group,
(2009). Vascular calcifications, vertebral fractures and mortality in haemodialysis patients. Nephrol Dial Transplant
24: 239-246
[Abstract][Full Text]
Cseprekal, O., Kis, E., Schaffer, P., Othmane, T. E. H., Fekete, B. Cs., Vannay, A., Szabo, A. J., Remport, A., Szabo, A., Tulassay, T., Reusz, G. S.
(2009). Pulse wave velocity in children following renal transplantation. Nephrol Dial Transplant
24: 309-315
[Abstract][Full Text]
Toussaint, N. D., Lau, K. K., Strauss, B. J., Polkinghorne, K. R., Kerr, P. G.
(2009). Determination and Validation of Aortic Calcification Measurement from Lateral Bone Densitometry in Dialysis Patients. CJASN
4: 119-127
[Abstract][Full Text]
Noonan, W., Koch, K., Nakane, M., Ma, J., Dixon, D., Bolin, A., Reinhart, G.
(2008). Differential effects of vitamin D receptor activators on aortic calcification and pulse wave velocity in uraemic rats. Nephrol Dial Transplant
23: 3824-3830
[Abstract][Full Text]
Honkanen, E., Kauppila, L., Wikstrom, B., Rensma, P. L., Krzesinski, J.-M., Aasarod, K., Verbeke, F., Jensen, P. B., Mattelaer, P., Volck, B., on behalf of the CORD study group,
(2008). Abdominal aortic calcification in dialysis patients: results of the CORD study. Nephrol Dial Transplant
23: 4009-4015
[Abstract][Full Text]
Amann, K.
(2008). Media Calcification and Intima Calcification Are Distinct Entities in Chronic Kidney Disease. CJASN
3: 1599-1605
[Abstract][Full Text]
Fishbane, S., Shapiro, W. B., Corry, D. B., Vicks, S. L., Roppolo, M., Rappaport, K., Ling, X., Goodman, W. G., Turner, S., Charytan, C.
(2008). Cinacalcet HCl and Concurrent Low-dose Vitamin D Improves Treatment of Secondary Hyperparathyroidism in Dialysis Patients Compared with Vitamin D Alone: The ACHIEVE Study Results. CJASN
3: 1718-1725
[Abstract][Full Text]
Malluche, H. H., Mawad, H., Monier-Faugere, M.-C.
(2008). Effects of Treatment of Renal Osteodystrophy on Bone Histology. CJASN
3: S157-S163
[Abstract][Full Text]
Shroff, R. C., McNair, R., Figg, N., Skepper, J. N., Schurgers, L., Gupta, A., Hiorns, M., Donald, A. E., Deanfield, J., Rees, L., Shanahan, C. M.
(2008). Dialysis Accelerates Medial Vascular Calcification in Part by Triggering Smooth Muscle Cell Apoptosis. Circulation
118: 1748-1757
[Abstract][Full Text]
Barraclough, K. A., Stevens, L. A., Er, L., Rosenbaum, D., Brown, J., Tiwari, P., Levin, A.
(2008). Coronary artery calcification scores in patients with chronic kidney disease prior to dialysis: reliability as a trial outcome measure. Nephrol Dial Transplant
23: 3199-3205
[Abstract][Full Text]
Shroff, R. C., Shah, V., Hiorns, M. P., Schoppet, M., Hofbauer, L. C., Hawa, G., Schurgers, L. J., Singhal, A., Merryweather, I., Brogan, P., Shanahan, C., Deanfield, J., Rees, L.
(2008). The circulating calcification inhibitors, fetuin-A and osteoprotegerin, but not Matrix Gla protein, are associated with vascular stiffness and calcification in children on dialysis. Nephrol Dial Transplant
23: 3263-3271
[Abstract][Full Text]
Arcidiacono, M. V., Cozzolino, M., Spiegel, N., Tokumoto, M., Yang, J., Lu, Y., Sato, T., Lomonte, C., Basile, C., Slatopolsky, E., Dusso, A. S.
(2008). Activator Protein 2{alpha} Mediates Parathyroid TGF-{alpha} Self-Induction in Secondary Hyperparathyroidism. J. Am. Soc. Nephrol.
19: 1919-1928
[Abstract][Full Text]
Kobayashi, S., Oka, M., Maesato, K., Ikee, R., Mano, T., Hidekazu, M., Ohtake, T.
(2008). Coronary Artery Calcification, ADMA, and Insulin Resistance in CKD Patients. CJASN
3: 1289-1295
[Abstract][Full Text]
Hsu, J. J., Tintut, Y., Demer, L. L.
(2008). Vitamin D and Osteogenic Differentiation in the Artery Wall. CJASN
3: 1542-1547
[Abstract][Full Text]
Mehrotra, R., Martin, K. J., Fishbane, S., Sprague, S. M., Zeig, S., Anger, M., for the Fosrenol Overview Research Evaluation Stud,
(2008). Higher Strength Lanthanum Carbonate Provides Serum Phosphorus Control With a Low Tablet Burden and Is Preferred by Patients and Physicians: A Multicenter Study. CJASN
3: 1437-1445
[Abstract][Full Text]
Rohrscheib, M. R., Myers, O. B., Servilla, K. S., Adams, C. D., Miskulin, D., Bedrick, E. J., Hunt, W. C., Lindsey, D. E., Gabaldon, D., Zager, P. G., for the DCI Medical Directors,
(2008). Age-related Blood Pressure Patterns and Blood Pressure Variability among Hemodialysis Patients. CJASN
3: 1407-1414
[Abstract][Full Text]
London, G. M., Marchais, S. J., Guerin, A. P., Boutouyrie, P., Metivier, F., de Vernejoul, M.-C.
(2008). Association of Bone Activity, Calcium Load, Aortic Stiffness, and Calcifications in ESRD. J. Am. Soc. Nephrol.
19: 1827-1835
[Abstract][Full Text]
Schlieper, G., Hristov, M., Brandenburg, V., Kruger, T., Westenfeld, R., Mahnken, A. H., Yagmur, E., Boecker, G., Heussen, N., Gladziwa, U., Ketteler, M., Weber, C., Floege, J.
(2008). Predictors of low circulating endothelial progenitor cell numbers in haemodialysis patients. Nephrol Dial Transplant
23: 2611-2618
[Abstract][Full Text]
Nakamura, M., Marui, Y., Ubara, Y., Nakanishi, S., Takemoto, F., Takaichi, K., Tomikawa, S.
(2008). Effects of percutaneous ethanol injection therapy on subsequent surgical parathyroidectomy. NDT Plus
1: iii39-iii41
[Abstract][Full Text]
Hunley, T. E., Kon, V., Jabs, K.
(2008). Myocardial Infarction in Chronic Kidney Disease. Pediatrics
122: 223-224
[Full Text]
How, P. P., Mason, D. L., Lau, A. H.
(2008). Current Approaches in the Treatment of Chronic Kidney Disease Mineral and Bone Disorder. Journal of Pharmacy Practice
21: 196-213
[Abstract]
Raggi, P., Kleerekoper, M.
(2008). Contribution of Bone and Mineral Abnormalities to Cardiovascular Disease in Patients with Chronic Kidney Disease. CJASN
3: 836-843
[Abstract][Full Text]
Yamada, K., Fujimoto, S.
(2008). Reply. Nephrol Dial Transplant
23: 1457-1458
[Full Text]
Ix, J. H., Katz, R., Kestenbaum, B., Fried, L. F., Kramer, H., Stehman-Breen, C., Shlipak, M. G.
(2008). Association of Mild to Moderate Kidney Dysfunction and Coronary Calcification. J. Am. Soc. Nephrol.
19: 579-585
[Abstract][Full Text]
Bolland, M. J, Barber, P A., Doughty, R. N, Mason, B., Horne, A., Ames, R., Gamble, G. D, Grey, A., Reid, I. R
(2008). Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ
336: 262-266
[Abstract][Full Text]
Winzenberg, T., Jones, G.
(2008). Recommended Calcium Intakes in Children: Have We Set the Bar Too High?. IBMS BoneKEy
5: 59-68
[Abstract][Full Text]
Toussaint, N. D., Lau, K. K., Strauss, B. J., Polkinghorne, K. R., Kerr, P. G.
(2008). Associations between vascular calcification, arterial stiffness and bone mineral density in chronic kidney disease. Nephrol Dial Transplant
23: 586-593
[Abstract][Full Text]
Arcidiacono, M. V., Sato, T., Alvarez-Hernandez, D., Yang, J., Tokumoto, M., Gonzalez-Suarez, I., Lu, Y., Tominaga, Y., Cannata-Andia, J., Slatopolsky, E., Dusso, A. S.
(2008). EGFR Activation Increases Parathyroid Hyperplasia and Calcitriol Resistance in Kidney Disease. J. Am. Soc. Nephrol.
19: 310-320
[Abstract][Full Text]
Phan, O., Ivanovski, O., Nikolov, I. G., Joki, N., Maizel, J., Louvet, L., Chasseraud, M., Nguyen-Khoa, T., Lacour, B., Drueke, T. B., Massy, Z. A.
(2008). Effect of oral calcium carbonate on aortic calcification in apolipoprotein E-deficient (apoE-/-) mice with chronic renal failure. Nephrol Dial Transplant
23: 82-90
[Abstract][Full Text]
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