Abstract
Background and Aims
Cardiac valve calcification (CVC) is a common disorder in patients with end stage kidney disease (ESKD) and is a predictor of cardiovascular disease and all-cause mortality. Several risk factors are related to CVC in patients with ESKD which include higher age, dyslipidemia, hypertension and diabetes as well as inflammation, bone mineral disease and malnutrition. Moreover, visceral adiposity is associated with disturbed lipid metabolism and proinflammatory activity which could predispose for CVC. Furthermore, sarcopenia and dynapenia is a state common in patients with ESKD. Thus, the aim of this cross-sectional study is to investigate the relationship of adiposity, components of sarcopenia and malnutrition with cardiac valves calcification in patients on chronic hemodialysis.
Method
Adult patients that were on maintenance hemodialysis were eligible for entering the study. Recruitment took place from March 2019 to September 2020. Exclusion criteria included, patients with less than 6 months on hemodialysis, patients with cancer, inflammatory bowel disease, severe infection, cardiac valve disease prior to dialysis initiation, history of parathyroidectomy and intravenous albumin administration 3 months prior to nutritional assessment. Calcification of heart valves and systolic and diastolic function was assessed by using two-dimensional echocardiography. Nutritional assessment was made using the Geriatric Nutritional Risk Index. Conicity Index, Waist to Height Ratio, the Visceral Adiposity Index, the Lipid Accumulation Product, the Height to Waist Phenotype were also calculated. Waist, calf and mid arm circumference measurement was performed in the end of a midweek dialysis session. Muscle strength was based on a measurement of hand grip strength using a hydraulic hand dynamometer in the non-fistula hand prior to dialysis session. Dynapenia was considered for values < 16 kg in females and < 27kg in males. Serum biochemistry parameters such as total protein, albumin, calcium, phosphate, total cholesterol, triglycerides, HDL, LDL, CRP and iPTH were also measured.
Results
Overall, 130 patients were included in the study with a mean age of 66±12.47 years (68.5% males) and an average dialysis duration of 4.37±4.95 years. No cardiac valve calcification was found in 34.6%, while both aortic and mitral valve calcification was found in 41.5% of patients. Calcification only of the aortic (AVC) or mitral (MVC) valve was found in 14.6% and 9.2% respectively. Compared to non AVC group, AVC group had significantly higher age, higher prevalence of diastolic dysfunction, CRP values and CRP/albumin ratio and lower albumin to total proteins ratio. Patients with MVC showed significantly higher prevalence of diastolic dysfunction, higher levels of iPTH, CRP/albumin ratio and lower albumin to total proteins ratio. Adiposity, nutritional, anthropometric indices and sarcopenia parameters such as creatinine index, muscle power and physical performance status did not show any difference between all CVC groups. Increased age [OR (95%CI):1.06 (1.00-1.12) p=0.05], diastolic dysfunction [OR (95%CI): 3.07 (1.05-8.92); p=0.04], CRP/albumin ratio were associated with increased risk of AVC, whereas the CRP/albumin ratio appeared as the most powerful risk factor for mitral and for any CVC [OR (95%CI): 3.41 (1.40-8.28); p=0.007, OR (95%CI): 7.98 (2.62-24.98) p<0.001, respectively]. ROC analysis indicated that increased values of CRP/albumin ratio are strong positive predictors of AVC [AUC, 95%CI 0.66 (0.56-0.75) p=0.002], MVC [AUC, 95%CI 0.642 (0.545-0.74) p=0.005] and calcification of any valve [AUC, 95%CI 0.71 (0.615-0.806) p<0.001].
Conclusion
Adiposity, nutritional, anthropometric indices and sarcopenia did not show to correlate with CVC in patients with ESKD on hemodialysis. Factors, such as diastolic dysfunction and notably increased CRP/albumin ratio were strong predictors of CVC.
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