Korean Circ J.  2021 Dec;51(12):961-982. 10.4070/kcj.2021.0995.

Vascular Calcification in Chronic Kidney Disease: Distinct Features of Pathogenesis and Clinical Implication

• Kim JS
• Hwang HS

• KMID: 2523162
• DOI: http://doi.org/10.4070/kcj.2021.0995

Abstract

Chronic kidney disease (CKD) is associated with a higher prevalence of vascular calcification (VC) and cardiovascular disease. VC in CKD patients showed different pathophysiological features from those of the general population. The pathogenesis of VC in CKD is a highly organized process, and prior studies have suggested that patients with CKD have their own specific contributors to the phenotypic change of vascular smooth muscle cells (VSMCs), including uremic toxins, CKD-mineral and bone disease (CKD-MBD), inflammation, and oxidative stress. For the diagnosis and monitoring of VC in CKD, several imaging modalities, including plain radiography, ultrasound, and computed tomography have been utilized. VC in CKD patients has distinct clinical features and implications. CKD patients revealed a more intense and more prevalent calcification on the intimal and medial layers, whereas intimal calcification is predominantly observed in the general population. While a higher VC score is clearly associated with a higher risk of all-cause mortality and cardiovascular events, a greater VC score in CKD patients does not fully reflect the burden of atherosclerosis, because they have more calcification at equal volumes of atheromatous plaques. The primary goal of VC treatment in CKD is the prevention of VC progression, and the main management is to control the biochemical components of CKD-MBD. Cinacalcet and non-calcium-containing phosphate binders are the mainstay of VC prevention in CKD-MBD management. VC in patients with CKD is an ongoing area of research and is expected to advance soon.

Keyword

Vascular calcification; Chronic kidney disease; Pathogenesis; Clinical implication

Figure

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  Figure 1 Immunohistochemistry of von Kossa, fetuin-A, and CRP in the iliac artery of kidney transplant recipients. Scale bar 100 μm. Original magnification×100.39) CRP = C-reactive protein.

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  Figure 2 (A) In patients without renal dysfunction, calcification is deposited in the intimal layer; (B) CKD patients obtain the medial calcification in the absence of the atherosclerotic factor, because mineral bone disorder accelerates the calcific process; (C) In clinical practice, intimal and medial calcification frequently co-exists in CKD patients, because they already had several traditional risk factors. Notably, the intimal or medial calcific burden is greater in CKD patients than in non-CKD patients.CKD = chronic kidney disease.

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  Figure 3 The prevalence of coronary artery calcification in different CKD stages. KSN News Factsheet Vol. 15 (Sep. 2019).CKD = chronic kidney disease; KSN = Korean Society of Nephrology.

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  Figure 4 Clinical connection of vascular calcification to cardiovascular or non-cardiovascular organs in CKD.CKD = chronic kidney disease; LVH = left ventricular hypertrophy.

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  Figure 5 Target achievement of the CKD-MBD parameters and mortality risk in dialysis patients. KSN News Factsheet Vol. 18 (May 2020).Ca = calcium; CKD-MBD = chronic kidney disease-mineral and bone disease; HR = hazard ratio; KSN = Korean Society of Nephrology; P = phosphate; iPTH = intact parathyroid hormone.

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