Coronary artery calcification, cardiovascular events, and death: a prospective cohort study of incident patients on hemodialysis

Background Coronary calcification in patients with end-stage renal disease (ESRD) is associated with an increased risk of cardiovascular outcomes and death from all causes. Previous evidence has been limited by short follow-up periods and inclusion of a heterogeneous cluster of events in the primary analyses. Objective To describe coronary calcification in patients incident to ESRD, and to identify whether calcification predicts vascular events or death. Design Prospective substudy of an inception cohort. Setting Tertiary care haemodialysis centre in Ontario (St Joseph’s Healthcare Hamilton). Participants Patients starting haemodialysis who were new to ESRD. Measurements At baseline, clinical characterization and spiral computed tomography (CT) to score coronary calcification by the Agatston-Janowitz 130 scoring method. A primary outcome composite of adjudicated stroke, myocardial infarction, or death. Methods We followed patients prospectively to identify the relationship between cardiac calcification and subsequent stroke, myocardial infarction, or death, using Cox regression. Results We recruited 248 patients in 3 centres to our main study, which required only biochemical markers. Of these 164 were at St Joseph’s healthcare, and eligible to participate in the substudy; of these, 51 completed CT scanning (31 %). Median follow up was 26 months (Q 1 , Q 3 : 14, 34). The primary outcome occurred in 16 patients; 11 in the group above the median and 5 in the group below ( p = 0.086). There were 26 primary outcomes in 16 patients; 20 (77 %) events in the group above the coronary calcification median and 6 (23 %) in the group below ( p = 0.006). There were 10 deaths; 8 in the group above the median compared with 2 in the group below ( p = 0.04). The hazard ratios for coronary calcification above, compared with below the median, for the primary outcome composite were 2.5 (95 % CI 0.87, 7.3; p = 0.09) and 1.7 (95 % CI 0.55, 5.4; p = 0.4), unadjusted and adjusted for age, respectively. For death, the hazard ratios were 4.6 (95 % CI 0.98, 21.96; p = 0.054) and 2.4 (95 % CI 0.45, 12.97; p = 0.3) respectively. Limitations We were limited by a small sample size and a small number of events. Conclusions Respondent burden is high for additional testing around the initiation of dialysis. High coronary calcification in patients new to ESRD has a tendency to predict cardiovascular outcomes and death, though effects are attenuated when adjusted for age.