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Pulse Wave Velocity is Inversely Related to Vertebral Bone ...
 

Pulse Wave Velocity is Inversely Related to Vertebral Bone ...

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    Pulse Wave Velocity is Inversely Related to Vertebral Bone ... Pulse Wave Velocity is Inversely Related to Vertebral Bone ... Presentation Transcript

    • Pulse Wave Velocity is Inversely Related to Vertebral Bone Density in Hemodialysis Patients Paolo Raggi MD 1 Antonio Bellasi, MD 1,2 Emiliana Ferramosca, MD 3 Geoffrey Block, MD 4 Muntner Paul, PhD 5 1 Division of Cardiology and Department of Medicine and Radiology, Emory University School of Medicine, Atlanta, GA; 2 Department of Nephrology, Ospedale San Paolo and University of Milan, Milan, Italy; 3 Department of Nephrology, Ospedale Malpighi and University of Bologna, Bologna, Italy; 4 Denver Nephrology, PC, Denver, CO; 5 Department of Epidemiology, Tulane University, New Orleans, LA Hypertension 2007; 49:1278-1284
    • Muntner et al., JASN, 2002 CV Mortality and Chronic Kidney Disease (CKD) : 0 5 10 15 20 25 30 35 40 >90 <89>70 <70 GFR (ml/min) CV deaths/1000 persons/yr Mann et al., Ann Intern Med, 2001 0 2 4 6 8 10 12 14 16 Total Mortality CV mortality MI Heart failure (%) CrCl >65ml/min CrCl <65ml/min
    • GFR 45-59 ml/min/1.73m 2 GFR 30-44 ml/min/1.73m 2 GFR 15-29 ml/min/1.73m 2 GFR <15 ml/min/1.73m 2 All cause of mortality CV Events Hospitalization Adjusted risk N=1.120.295 All-Cause and CV Mortality and Glomrular Filtration Rate (GFR) : Go et al. N. Engl J Med, 351:1296-305,2004
    • Relative Risk of Death by Serum Phosphorus in Haemodialysis Patients Block GA et al. J Am Soc Nephrol 2004 (n=40,538) Serum phosphorus (mg/dL) 3–4 4–5 5–6 6–7 7–8 <3 8–9 >9 2.2 2.0 1.8 1.6 1.4 1.2 1.0 0.0 Relative risk of death Ref. 2.4 RR 25% if P> 6 mg/dl!
    • Bone morphogenic protein type 2a Osteopontin MGP (matrix mineral-binding protein) PTH- related peptide PHOSPHORUS/ CALCIUM Cbfa-1 Osteocalcin Osteoprotegerin Bone Sialoprotein Osteonectin ALP Fetuin-A Pyrophosphate Vascular Calcification: a Link Between Bone Mineral Abnormalities and Mortality? Adapted from Cozzolino et al, J Am Soc Nephrol 2001.
    • Aortic Calcification (% /year) Bone Density (% /year) 1st N=39 (70 + 9.9) 2nd N=39 (71 + 8.1) 3rd N=39 (68 + 8.0) 4th N=40 (68 + 9.2) Quartiles P<0.03 P<0.002 P<0.001 60 45 30 15 0 -1.5 -3.0 -4.5 -6.0 Bone Density and Aortic Calcification in The General Population Schultz A et al J Clin Endocrinol Metab. 2004
    • Change in vertebral bone density -8 -6 -4 -2 0 2 4 6 Sevelamer Calcium salts Trabecular Cortical * * *P<0.05 % change (hounsfield units) 5% 2% -7% -2% -75 -25 25 75 125 175 CALCIUM (N=70) SEVELAMER (N=62) -46 + 88 151 + 56 Raggi et al.J Bone Min Res 2005
    • Aims of the study: 1) Assess the relationship of bone mineral density (BMD) and a noninvasive measure of CV risk, such as PWV, in CKD-5 patients. 2) Compare the reliability of dual energy x-ray absorptiometry (DEXA) and quantitative computed tomography (QCT) Raggi et al. Hypertension 2007; 49:1278-1284
    • Study Design: D.O.V.E. (Dialysis Outcome, Vascular Evaluation): Multicenter, cross-sectional, one-arm, non invasive study of cardiovascular disease in chronic dialysis patients 110 patients patients on maintenance dialysis (more than 3 months) from 2 centers (New Orleans, LA; Denver, CO) Raggi et al. Hypertension 2007; 49:1278-1284
    • Aortic Pulse Wave Velocity (aPWV) was assessed by applanation tonometry with the Sphygmocor Vx Software (AtCor Medical, Sydney, Au) Methods: arterial stiffness High compliance=Low PWV Low compliance=High PWV
    • Methods: BMD assessment Bone Mineral Assessment (BMD) (1) BMD was assessed by Quantitative Computed Tomography (QCT). This is a highly reliable technique to measure BMD of the thoracic spine (2) Lumbar spine BMD was also assessed by dual energy x-ray absorptiometry (DEXA) Raggi et al. Hypertension 2007; 49:1278-1284
    • Results: Age Standardized PWV by Tertile of BMD and T-scores Assessed by QCT Raggi et al. Hypertension 2007; 49:1278-1284 1 0 . 6 1 0 . 4 8 . 7 8 9 1 0 1 1 1 2 < 1 2 8 1 2 8 t o 1 8 3 > 1 8 4 B o n e m i n e r a l d e n s i t y , m g / c c 1 0 . 6 1 0 . 4 8 . 6 8 9 1 0 1 1 1 2 < - 1 . 7 4 - 1 . 7 4 t o 0 . 4 7 > 0 . 4 8 T e r t i l e o f T - s c o r e * p - t r e n d = 0 . 0 2 7 * p - t r e n d = 0 . 0 3 0 Pulse wave velocity, m/sec Pulse wave velocity, m/sec
    • Age Standardized Prevalence and Adjusted Odds Ratios of PWV > 9 m/sec Associated with Tertile of BMD P-trend<0.001 Age adjusted prevalence of PWV > 9 m/sec by t-score tertiles < -1.74 -1.74 - 0.47 > 0.48 1 < -1.74 -1.74 - 0.47 0.39 (0.11, 1.38) > 0.48 0.21 (0.04, 1.04) Ref.
        • *Adjusted for age, sex, dialysis vintage, current smoking, body mass index, and diabetes mellitus
      Odds ratio (95% CI) p-trend=0.04*
    • Age Standardized Prevalence and Adjusted Odds Ratios of PWV > 9 m/sec Associated with Tertile of BMD P-trend<0.001 Age adjusted prevalence of PWV > 9 m/sec by BMD tertiles < 127 mg/cc 128 - 183 mg/cc > 184 mg/cc Odds ratio (95% CI) p-trend=0.04* 1 < 127 mg/cc 128 - 183 mg/cc 0.38 (0.11, 1.36) > 184 0.22 (0.04, 1.12) Ref.
        • *Adjusted for age, sex, dialysis vintage, current smoking, body mass index, and diabetes mellitus
    • Correlation Between T-scores Measured by QCT and DEXA in Presence and in Absence of Aortic Calcification T-score: DEXA and QCT correlation 0.6 0.37 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 No calcification Calcification Present 0.42 0.94 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 Abdominal Aorta X-ray Thoracic Aorta Computed Tomography T-score: DEXA and QCT correlation No calcification Calcification Present Raggi et al. Hypertension 2007; 49:1278-1284
    • Conclusions:
      • It appears to be an association between BMD status and vascular stiffness among hemodialysis patients.
      • DEXA is not a reliable measure of spine BMD and QCT should be used instead