Prevalence of Abdominal Aortic Calcification in Maintenance
Hemodialysis Patients
R. A. Muzasti
1*
, R. Loesnihari
2
1
Division Nephrology and Hypertension, Departement of Internal Medicine, Medical Faculty, Universitas
Sumatera Utara, Medan, North Sumatera, Indonesia
2
Departement of Clinical Pathology, Medical Faculty, Universitas Sumatera Utara, Medan, North Sumatera,
Indonesia
Keywords: Hemodialysis, Abdominal Aortic Calcification, Prevalence
Abstract: Based on Indonesian Renal Registry Data in 2016, the cause of death of most hemodialysis patients was
cardiovascular disease about 41%. One of the prognostic markers of the death caused by cardiovascular
disease is vascular calcification. The prevalence of vascular calcification in hemodialysis patients varies,
depending on the detection method and the location of calcification. Data on vascular calcification in
Indonesia is limited. Primary endpoint of this study was prevalence of abdominal aortic calcification. This
was an observational study of 76 consecutive adult patients on maintenance hemodialysis for ⩾36 months in
Rasyida Hospital on April 2018. Abdominal aortic calcification was determined by plain lateral lumbar X-
ray. Most of patients were male (61.8%) and had hypertension (75%). Patients’ median (min-max) age was
57 (25-78) years and median (min-max) dialysis duration was 67 (36-231) months. Fifty-two patients (68.4%)
had abdominal aortic calcification. Severe abdominal aortic calcification were in 40 patients (52.6%). Most
of patients had vascular calcification in both of layers; intima and media (44.7%). Vascular calcification are
highly prevalent in the hemodialysis patient. Further studies were needed evaluating the association between
characteristic of demographic, clinical and labortorium with vascular calcification.
1 INTRODUCTION
The mortality rate of hemodialysis patients is very
high. Muzasti found that 5 years mortality rate of
chronic hemodialysis patients in Indonesia was
62.2% (Muzasti, 2018). Sibarani et al in 2016 found
that 1 year mortality rate in of chronic hemodialysis
patients was 36,6% (Sibarani, 2018). The risk of
death in the group of 25-34 years old is higher (up to
1000 times) than in the general population as well as
in patients aged 45 years (up to 100 times) (Kuzniar,
2008). One of the major causes of mortality in many
countries is cardiovascular disease (CVD). According
to Indonesian Renal Registry in 2016, the cause of
mortality of most hemodialysis patients in Indonesia
was cardiovascular disease about 41% (IRR, 2017).
One of the prognostic markers of mortality from
cardiovascular disease in hemodialysis patients is
vascular calcification. Research over the past decade
shows that vascular calcification in chronic kidney
disease is no longer just a passive degenerative
phenomenon but a complex and active pathological
process due to metabolic and mineral bone disorders
(Giachelli, 2009). Appropriate management of
mineral and bone metabolism disorders, according to
the US National Kidney Foundation includes
assessment of vascular calcification (KDIGO, 2016).
The prevalence of vascular calcification in a regular
HD patient ranges from 23-87.5% depending on the
detection method and the location of calcification
(Gorriz, 2015).
There are several imaging methods in detecting
vascular calcification. Unfortunately, none have been
used as a gold standard in assessing this vascular
calcification (Jayalath, 2005). However, the US
National Kidney Foundation still recommends
examination of lateral abdominal plain images to
detect the presence or absence of vascular
calcification in patients with stage 3 to 5 chronic
kidney disease (KDIGO, 2016).
Few studies have evaluated vascular calcification
in hemodialysis patients in developing countries such
Muzasti, R. and Loesnihari, R.
Prevalence of Abdominal Aortic Calcification in Maintenance Hemodialysis Patients.
DOI: 10.5220/0010076705090513
In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramification Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages
509-513
ISBN: 978-989-758-449-7
Copyright
c
2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
509
as Indonesia. This study was undertaken to determine
prevalence of vascular calcification in maintenance
hemodialysis patients using lateral lumbar X-ray.
2 METHODS
The present study was a observational cross sectional
study on maintenance hemodialysis patients at
Rasyida Hospital Medan in April 2018. Each medical
record was reviewed to verify the diagnosis and to
obtain all relevant demographic and clinical data.
2.1 Patients
2.1.1 Study Population
All patients who undergo haemodialysis in Rasyida
Renal Hospital Medan were population in this study.
2.1.2 Sample
All patients undergoing haemodialysis in Rasyida
Hospital Medan in April 2018 and met the
recruitment criteria were samples in this study
.
2.1.3 Recruitment Criteria
1) Inclusion Criteria
a. Regular hemodialysis for ⩾36 months
b. Age ≥18 years
c. Willing in doing lateral lumbar X-ray
2) Exclusion Criteria
a. Patients with lack of medical record
2.2 Methods of Collecting Data
The presence and degree of vascular calcifications
was assessed by abdominal aortiic calcification
scores from lateral lumbar X-rays. Assessment using
abdominal aortic segments; anterior and posterior
walls that lie in front of the lumbar vertebra one to
four (L1-L4):
0 = no calcific deposits in front of vertebra
1 = small scattered calcific deposits ⩽1/3 of segment
2 = calcification of 1/3 to 2/3 of the segment’s aortic
wall
3 = 2/3 or more of the wall calcified.
Based on this scoring system, the minimum value
of abdominal aorta combined calcification scores is 0
to a maximum of 24. It is no calcification if the score
is 0, mild calcification if the score is 1-4, severe
calcification if the score is above 4 (
Honkanen, 2008)
.
The difference between intima and media
calcifications can also be determined by this
examination, that is, if there are radio-opaque images
such as patches and pieces with irregular and patchy
distributions, called intima calcifications, whereas
radio-opaque images such as straight lines such as
rail-road track is referred as media calcification
(
Hashimoto
, 2008).
Demographic and clinical data recorded in
frequency of hemodialysis, duration of hemodialysis,
the etiology of renal failure, body weight and height
to determine body mass index, age, gender. This
study was conducted after obtaining approval from
the Commission of Ethics FK USU-RSUP HAM on
the implementation of health research. All
participants granted written informed consent.
2.3 Statistical Analysis
All data were analyzed with statistical software SPSS
22.0 using univariate analysis. Data from categorical
variables are expressed in frequency (n) and
percentage (%), whereas data from numeric variables
are expressed in central size (mean, median or
proportion) and size of variation variation (standard
deviation or range).
3 RESULTS
We studied 76 hemodialysis patients (47 males, 29
females). Patients’ median (min-max) age was 57
(25-78) years with a mean (standard deviation [SD])
of age was 54.39 (11.32) years and median (min-max)
dialysis vintage was 67 (36-231) months with a mean
(SD) dialysis vintage of 73.24 (35.11) months. Renal
failure etiologies were diabetic nephropathy in 14
(18.4%) of patients and hypertension in 57 (75%) of
patients. A total of 12 (15.8%) patients had history of
cardiovascular disease and 24
(31.6%) % patients
were tobacco-smokers.
Figure 1: Distribution of 76 patients based on AAC.
0,0
50,0
31,6
15,8
32,9
11,8
5,3
2,6
Proportionofpatients%
Kaupilascore
ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramification Researches
510
Based on the lateral lumbar X-ray, the prevalence
of abdominal aortic calcification are 68.4% with the
mean (SD) abdominal aorta calcification scores are
5.07 (4.79) and median (min-max) abdominal aorta
calcification scores are 5 (0-19). Distribution of
patient that based on abdominal aortic calcification
scores is seen in Figure.1
Figure 2: Severity of vascular calcification according to
AAC scores
Based on abdominal aorta calcification scores,
there were 24 patients (31.6%) did not has
calcification. Twelve patients (15.8%) had mild
calcification and 40 (52.6%) had severe calcification.
Figure 2 shows the degree of calcification based on
the abdominal aortic calcification scores.
Figure 3: Location of AAC
In addition to determine the calcification severity,
lateral lumbar X-rays may also determine the location
of calcification. Figure 3 shows that vascular
calcification was common in both layers; intima and
media were 34 patients (44,7%), followed by media
layer on 12 patients (15,8%) and tunica intima on 6
patients (31,6%).
Figure 4: Proportion of vascular calcification according to
gender
Figure 4 shows that patients who had calcification
were more men (59.60%) than women (48.30%).
While in patients who did not have calcification,
women (51.70%) were more than men (40.40%).
Figure 5: Proportion of vascular calcification according to
history of cardiovascular disease
Figure 5 shows that patients with history of CVD
(83.30%) were more than patients without a history
of CVD (50.00%) in the calcified patient group.
While in the non-calcified patient group, patients with
no history of CVD were more (50.00%) than patients
with a history of CVD (16.70%).
More smokers (70.80%) than non-smokers
(48.10%) in the calcified patient group. Whereas in
the non-calcified patient group, the non-smokers
(51.90%) were higher than the smokers (29.20%).
31%
16%
53%
None
Mild
calcification
Severe
calcification
31,6
7,9
15,8
44,7
None
Intimalayer
Medialayer
Bothofintima
&media
Calcification(‐) Calcification(+)
40,40%
59,60%
51,70%
48,30%
Male
Female
50,00% 50,00%
16,70%
83,30%
0,00%
20,00%
40,00%
60,00%
80,00%
100,00%
Calcification(‐)Calcification(+)
HistoryofCVD(‐) HistoryofCVD(+)
Prevalence of Abdominal Aortic Calcification in Maintenance Hemodialysis Patients
511
4 DISCUSSION
To date, no imaging method has been used as a gold
standard in assessing vascular calcification (KDIGO,
2016). However, the US National Kidney Foundation
still recommends examination of lateral lumbal X-
rays to detect vascular calcification in patients with
stage 3 to 5 chronic kidney disease (KDIGO, 2016).
In this study, the prevalence of vascular
calcification was 68.4%. Publications in recent years
have shown that the prevalence of vascular
calcification in regular hemodialysis patients ranges
from 23-87.5% depending on the detection method
and the location of calcification. Using Electron-
Bearn Computed-Tomography (EBCT), there was
vascular calcification in 87.5% of young
hemodialysis patients (20-30 years) (Gorriz, 2015). A
study by Shantha et al stated that the abdominal aortic
calcification score has a fairly good diagnostic value
in detecting vascular and valve calcification when
compared with ultrasound and echocardiography in
regular hemodialysis patients. The technique also
showed a high correlation with the score used on
EBCT, which were 87.5% in sensitivity, 75% in
specificity, positive predictive value was 82,% and
negative predictive value was 80.9% for abdominal
aortic calcification score> 9.375%. However, when
compared with Multi Slice Computed-Tomography
(MSCT), the examination using lateral lumbal X-rays
is highly subjective and less sensitive (Li ES, 2010).
When compared to the results of this study with
previous research, it was seen that the prevalence of
vascular calcification is almost the same. Research
conducted in France obtained vascular calcification
as much as 68%, while in Australia found a greater
prevalence of 90%. Separate studies conducted in
Japan and Brazil have a prevalence of 50-60%
vascular calcification (Guillermo, 2017).
Vascular calcification in chronic kidney disease
can occur in both artery layers, ie, intima and media.
Both types can be observed through the abdominal
aorta, although calcification in media layer is more
common (Jayalath, 2005). In this study it was found
that vascular calcification was most common in both
artery layers; intima and media.
Kraus et al found that moderate / severe
calcification at the abdominal aortic was more
prevalent in men than in women (Krauss, 2015). The
study also showed the same result that more males
experienced vascular calcification than females.
This study shows that history of cardiovascular
diseases was associated with abdominal aortic
calcification scores. This is similar to that of
Guillermo et al and Kraus et al (Guillermo,
2017;Krauss, 2015). Even in the study of
Calcification Outcome in Renal Disease (CORD) it
was stated that a history of cardiovascular diseases
was associated with higher AAC scores and predicted
calcification on multivariate analysis (Krauss, 2015)
5 CONCLUSION
Vascular calcification are highly prevalent in the
hemodialysis patients. Further studies were
needed evaluating the association between
characteristic of demographic, clinical and
laboratorium with vascular calcification.
Conflict of Interests: None to declare.
Funding: Universitas Sumatera Utara supported this
work in accordance with Talenta research
implementation contracts 2018, number:
2590/UN5.1.R/PPM/2017 March 16, 2018.
REFERENCES
Muzasti RA, Lubis HR 2018 Association of phase
angle on bioelectrical impedance analysis and
dialysis frequency with survival of chronic
hemodialysis patients Earth and Environmental
Science Vol 125 p 01211.
Sibarani H, Muzasti RA, and Lubis HR 2018
Association between neutrophil-to-lymphocyte
ratio and survival rate patient hemodialysis in
Adam Malik general hospital in 2016. Earth and
Environmental Science Vol 125 p 012108.
Kuzniar J, Porazko T, Linger M 2008 Relationship
between fetuin-A concentration, elevated levels of
inflammatory markers, and arterial wall stiffness
in end-stage kidney disease J Ren Nutr Vol 18 p
83-6
Indonesian Renal Registry 2017 9
nd
Annual Report of
Indonesian Renal Registry Bandung.
Giachelli CM 2009. The emerging role of phosphate
in vascular calcification. Kidney Int Vol 75 p
890–7.
KDIGO 2016 Clinical Practice Guideline Update on
Diagnosis, Evaluation, Prevention and Treatment
of CKD-MBD. Available
at:http://www.kdigo.org/clinical_practice_guideli
nes/CKD-MBD%20Update/KDIGO%20CKD-
MBD%20Update_Public%20Review_Final.pdf
Gorriz JL, Molina P, Cervero´ n MJ, et al 2015
Vascular calcification in patients with nondialysis
ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramification Researches
512
CKD over 3 years Clin J Am Soc Nephrol Vol
10(4) p 654–66.
Jayalath R, Mangan S, Golledge J 2005 Aortic
calsification. Eur J Vasc Endovasc Sur Vol 30 p
476-88.
Honkanen E, Kauppila L, Rensma PL, et al 2008
Abdominal Aortic Calcification in Dialysis
Patient: Result of the CORD study Nephrology
Dialysis Transplantation Vol 23(12) p 4009-15.
Hashimoto H, Iijima K, Hashimoto H, et al 2008
Validity and Usefulness of Aortic Arch
Calcification in Chest X-Ray Journal of
Atherosclerotic and Thrombosis Vol 16(3) p 256-
264.
Li ES, Marbun MB, and Wulani V 2010 Nilai
Diagnostik Skor Kalsifikasi Arkus untuk
Diagnosis Kalsifikasi Vaskular Pada Pasien
Hemodialisa Rutin Ebers Papyrus Vol 16(3) p
153-70.
Guillermo RD, Griselda B, Graciela F, et al. 2017
Prevalence of factors related to vascular
calcification in patients chronic kidney disease on
dialysis Medicina (Buenos Aires) Vol 77 p 207-
213
Krauss MA, Kalra PA, Hunter J, et al. 2015 The
prevalence of vascular calcification in patients
with end-stage renal disease on hemodialysis: a
cross-sectional observational study Ther Adv
Chronic Dis Vol 6(3) p 84–96.
Prevalence of Abdominal Aortic Calcification in Maintenance Hemodialysis Patients
513
