What is the management approach for chronic and calcification lesions?

From the Guidelines

The management of chronic and calcification lesions should focus on treating patients with overt hyperphosphatemia and avoiding inappropriate calcium loading, while also considering the use of calcium-based phosphate binders and calcimimetics as treatment options. When managing chronic and calcification lesions, it is essential to consider the complexities of biochemical variables, such as serum phosphate, calcium, and PTH, as therapeutic maneuvers aimed at improving one variable often have unintended effects on others 1. Key considerations in the management approach include:

• Focusing treatment on patients with overt hyperphosphatemia, as current evidence does not show benefit to maintaining normal serum phosphate levels in patients not receiving dialysis 1
• Avoiding inappropriate calcium loading in adults whenever possible, as new evidence suggests that hypercalcemia may be harmful in all GFR categories of CKD 1
• Restricting the use of calcium-based phosphate binders in patients with hyperphosphatemia across the CKD spectrum 1
• Using calcimimetics, calcitriol, and vitamin D analogues as acceptable first-line options in patients receiving dialysis, while avoiding routine use of calcitriol or vitamin D analogues in patients not receiving dialysis due to the increased risk for hypercalcemia 1. Overall, the management of chronic and calcification lesions requires a comprehensive approach that takes into account the complex interplay of biochemical variables and the potential risks and benefits of different treatment options.

From the Research

Management Approach for Chronic and Calcification Lesions

The management approach for chronic and calcification lesions involves various techniques, including non-invasive and invasive imaging methods to detect and quantify vascular calcification.

• Computed tomography (CT) is a commonly used clinical examination method that can analyze vascular calcification 2.
• Emerging types of CT, such as dual-energy CT and micro CT, have also been applied to vascular imaging and providing anatomical information for calcification 2.
• The use of angiotensin-converting-enzyme inhibitor (ACEI) and/or angiotensin II receptor blocker (ARB) might be associated with vascular calcification in predialysis chronic kidney disease patients 3.
• Vascular calcification is a complex process expressing similarity to bone metabolism in onset and progression, and is promoted by various factors, including hyperphosphatemia, Ca/Pi imbalance, uremic toxins, chronic inflammation, oxidative stress, and activation of multiple signaling pathways 4.

Detection and Quantification of Vascular Calcification

Detection and quantification of vascular calcification can be achieved through various imaging modalities, including:

• Computed tomography (CT) 2, 3
• Radiography 5
• Intravascular imaging 5
• The total vascular calcification volume (Calc) can be calculated with a three-dimensional imaging software and standardized by body surface area (BSA) 3.

Risk Factors and Relationship with Plaque Progression

Vascular calcification is associated with various risk factors, including:

• Hyperphosphatemia 4
• Ca/Pi imbalance 4
• Uremic toxins 4
• Chronic inflammation 4
• Oxidative stress 4
• The relationship between vascular calcification and plaque progression is complex, and the evolution of coronary artery calcification is observed to occur concurrently with the progression of plaque 5.