Moderate-severe aortic arch calcification and high serum alkaline phosphatase co-modify the risk of cardiovascular events and mortality among chronic hemodialysis patients

Patients with end-stage kidney disease undergoing chronic hemodialysis (HD) have an unparalleled risk of vascular calcification (VC) and high alkaline phosphatase (Alk-P) levels. However, whether VC contributed to the cardiovascular risk modified by serum Alk-P levels was not addressed in the population.
A retrospective cohort study was conducted on chronic HD patients, between October 1 and December 31, 2018, with aortic arch calcification (AoAC) scores and serum Alk-P levels. Patients were categorized into four groups: non-to-mild AoAC/low Alk-P, non-to-mild AoAC/high Alk-P, moderate-to-severe AoAC/low Alk-P, and moderate-to-severe AoAC/high Alk-P. The Cox proportional hazard model and Kaplan–Meier analysis were used to evaluate the risks of major adverse cardiovascular effects (MACEs) and cardiovascular and all-cause mortality after multivariate adjustment.
Among 376 chronic HD patients recruited, 125 (33%) had non-to-mild AoAC/low Alk-P, 76 (20%) had non-to-mild AoAC/high Alk-P, 89 (24%) had moderate-to-severe AoAC/low Alk-P, and 86 (23%) had moderate-to-severe AoAC/high Alk-P. After 3 years of follow-up, patients with coexisting moderate-to-severe AoAC and high Alk-P had a higher risk of MACEs (aHR 1.76; 95% CI 1.06–2.92), and cardiovascular (aHR 2.49; 95% CI 1.21–5.11) and all-cause mortality (aHR 2.67; 95% CI 1.39–5.13) compared to those with non-to-mild AoAC/low Alk-P even after adjustments for significant clinical variables.
In chronic HD patients, moderate to severe AoAC co-existed with high Alk-P levels and enhanced the risk of MACEs and cardiovascular and all-cause mortality. Interventions to attenuate these risk factors simultaneously should be emphasized in this population.

罹患终末期肾病（end-stage kidney disease）并接受慢性血液透析（chronic hemodialysis, HD）的患者，发生血管钙化（vascular calcification, VC）的风险极高，且血清碱性磷酸酶（alkaline phosphatase, Alk-P）水平常显著升高。然而，在该患者群体中，血管钙化是否会通过血清碱性磷酸酶水平调节心血管疾病风险，目前尚未有相关研究予以阐明。

本研究针对2018年10月1日至12月31日期间的慢性血液透析患者开展回顾性队列研究，收集其主动脉弓钙化（aortic arch calcification, AoAC）评分与血清碱性磷酸酶水平。将患者分为四组：非轻度至轻度主动脉弓钙化/低碱性磷酸酶组、非轻度至轻度主动脉弓钙化/高碱性磷酸酶组、中度至重度主动脉弓钙化/低碱性磷酸酶组，以及中度至重度主动脉弓钙化/高碱性磷酸酶组。采用Cox比例风险模型与Kaplan-Meier分析，经多变量校正后，评估患者发生主要不良心血管事件（major adverse cardiovascular effects, MACEs）、心血管死亡率与全因死亡率的风险。

本次研究共纳入376例慢性血液透析患者，其中125例（33%）属于非轻度至轻度主动脉弓钙化/低碱性磷酸酶组，76例（20%）属于非轻度至轻度主动脉弓钙化/高碱性磷酸酶组，89例（24%）属于中度至重度主动脉弓钙化/低碱性磷酸酶组，86例（23%）属于中度至重度主动脉弓钙化/高碱性磷酸酶组。经过3年随访，即便校正了具有统计学意义的临床变量，合并中度至重度主动脉弓钙化与高碱性磷酸酶水平的患者，其主要不良心血管事件（校正后风险比aHR 1.76；95%置信区间CI 1.06~2.92）、心血管死亡率（aHR 2.49；95%CI 1.21~5.11）与全因死亡率（aHR 2.67；95%CI 1.39~5.13）均显著高于非轻度至轻度主动脉弓钙化/低碱性磷酸酶组患者。

在慢性血液透析患者中，中度至重度主动脉弓钙化与高碱性磷酸酶水平共存时，会进一步升高主要不良心血管事件、心血管死亡率与全因死亡率的发生风险。因此，临床中应重视对此类人群同时干预这两项危险因素。