{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,12]],"date-time":"2025-10-12T02:10:48Z","timestamp":1760235048261,"version":"build-2065373602"},"reference-count":48,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2021,7,13]],"date-time":"2021-07-13T00:00:00Z","timestamp":1626134400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Kaohsiung Municipal Hsiao-Kang Hospital","award":["S-109-06"],"award-info":[{"award-number":["S-109-06"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JPM"],"abstract":"<jats:p>Patients with end-stage renal disease have a higher risk of cardiovascular morbidity and mortality. In this study, we investigated the predictive ability of a combination of cardiothoracic ratio (CTR) and aortic arch calcification (AoAC) for overall and cardiovascular mortality in patients receiving hemodialysis. We also evaluated the predictive power of AoAC and CTR for clinical outcomes. A total of 365 maintenance hemodialysis patients were included, and AoAC and CTR were measured using chest radiography at enrollment. We stratified the patients into four groups according to a median AoAC score of three and CTR of 50%. Multivariable Cox proportional hazards analysis was used to identify the risk factors of mortality. The predictive performance of the model for clinical outcomes was assessed using the \u03c72 test. Multivariable analysis showed that, compared to the AoAC &lt; 3 and CTR &lt; 50% group, the AoAC \u2265 3 and CTR &lt; 50% group (hazard ratio [HR], 4.576; p &lt; 0.001), and AoAC \u2265 3 and CTR \u2265 50% group (HR, 5.912; p &lt; 0.001) were significantly associated with increased overall mortality. In addition, the AoAC &lt; 3 and CTR \u2265 50% (HR, 3.806; p = 0.017), AoAC \u2265 3 and CTR &lt; 50% (HR, 4.993; p = 0.002), and AoAC \u2265 3 and CTR \u2265 50% (HR, 8.614; p &lt; 0.001) groups were significantly associated with increased cardiovascular mortality. Furthermore, adding AoAC and CTR to the basic model improved the predictive ability for overall and cardiovascular mortality. The patients who had a high AoAC score and cardiomegaly had the highest overall and cardiovascular mortality among the four groups. Furthermore, adding AoAC and CTR improved the predictive ability for overall and cardiovascular mortality in the hemodialysis patients.<\/jats:p>","DOI":"10.3390\/jpm11070657","type":"journal-article","created":{"date-parts":[[2021,7,13]],"date-time":"2021-07-13T22:25:31Z","timestamp":1626215131000},"page":"657","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Aortic Arch Calcification and Cardiomegaly Are Associated with Overall and Cardiovascular Mortality in Hemodialysis Patients"],"prefix":"10.3390","volume":"11","author":[{"given":"Shih-Hsiang","family":"Ou","sequence":"first","affiliation":[{"name":"Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6915-3679","authenticated-orcid":false,"given":"Yi-Hsueh","family":"Liu","sequence":"additional","affiliation":[{"name":"Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan"},{"name":"Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tung-Ling","family":"Chung","sequence":"additional","affiliation":[{"name":"Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan"},{"name":"Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5897-2860","authenticated-orcid":false,"given":"Jiun-Chi","family":"Huang","sequence":"additional","affiliation":[{"name":"Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan"},{"name":"Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pei-Yu","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan"},{"name":"Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ho-Ming","family":"Su","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan"},{"name":"Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1610-4184","authenticated-orcid":false,"given":"Szu-Chia","family":"Chen","sequence":"additional","affiliation":[{"name":"Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung 812, Taiwan"},{"name":"Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan"},{"name":"Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,7,13]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1097\/00000441-200304000-00002","article-title":"Cardiovascular mortality in end-stage renal disease","volume":"325","author":"Collins","year":"2003","journal-title":"Am. J. Med. Sci."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1681\/ASN.2004030203","article-title":"Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999","volume":"16","author":"Foley","year":"2005","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.ijcard.2015.06.120","article-title":"Risk of major cardiovascular events among incident dialysis patients: A Korean national population-based study","volume":"198","author":"Kim","year":"2015","journal-title":"Int. J. Cardiol."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Duprez, D.A., Duval, S., Hoke, L., Florea, N., Grandits, G., Carlson, C., Lee, J., and Cohn, J.N. (2020). Early cardiovascular structural and functional abnormalities as a guide to future morbid events. Eur. J. Prev. Cardiol.","DOI":"10.1177\/2047487320901416"},{"key":"ref_5","first-page":"44","article-title":"The cardiovascular burden in end-stage renal disease","volume":"191","author":"Cozzolino","year":"2017","journal-title":"Expand. Hemodial."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1016\/S0140-6736(13)60595-4","article-title":"Chronic kidney disease and cardiovascular risk: Epidemiology, mechanisms, and prevention","volume":"382","author":"Gansevoort","year":"2013","journal-title":"Lancet"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"405","DOI":"10.1080\/00365590410031715","article-title":"Traditional and non-traditional risk factors as contributors to atherosclerotic cardiovascular disease in end-stage renal disease","volume":"38","author":"Yao","year":"2004","journal-title":"Scand. J. Urol. Nephrol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1111\/j.1542-4758.2009.00366.x","article-title":"Simple evaluation of aortic arch calcification by chest radiography in hemodialysis patients","volume":"13","author":"Ogawa","year":"2009","journal-title":"Hemodial. Int."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"658","DOI":"10.1159\/000368476","article-title":"Aortic arch calcification predicts cardiovascular and all-cause mortality in maintenance hemodialysis patients","volume":"39","author":"Komatsu","year":"2014","journal-title":"Kidney Blood Press. Res."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"256","DOI":"10.5551\/jat.E570","article-title":"Validity and usefulness of aortic arch calcification in chest X-ray","volume":"16","author":"Hashimoto","year":"2009","journal-title":"J. Atheroscler. Thromb."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2810","DOI":"10.1001\/jama.283.21.2810","article-title":"Calcification of the aortic arch: Risk factors and association with coronary heart disease, stroke, and peripheral vascular disease","volume":"283","author":"Iribarren","year":"2000","journal-title":"JAMA"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1016\/j.atherosclerosis.2009.11.012","article-title":"Aortic arch calcification detectable on chest X-ray is a strong independent predictor of cardiovascular events beyond traditional risk factors","volume":"210","author":"Iijima","year":"2010","journal-title":"Atherosclerosis"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1007\/s00380-011-0129-1","article-title":"Aortic arch calcification evaluated on chest X-ray is a strong independent predictor of cardiovascular events in chronic hemodialysis patients","volume":"27","author":"Inoue","year":"2012","journal-title":"Heart Vessel."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e3643","DOI":"10.1097\/MD.0000000000003643","article-title":"Association of brachial-ankle pulse wave velocity and cardiomegaly with aortic arch calcification in patients on hemodialysis","volume":"95","author":"Shin","year":"2016","journal-title":"Medicine"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1093\/ndt\/17.2.336","article-title":"Cardiovascular calcification in end-stage renal disease","volume":"17","author":"Salusky","year":"2002","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1016\/j.amjcard.2007.08.039","article-title":"A propensity-matched study of the association of cardiothoracic ratio with morbidity and mortality in chronic heart failure","volume":"101","author":"Giamouzis","year":"2008","journal-title":"Am. J. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"171","DOI":"10.2217\/fca.15.5","article-title":"Cardiothoracic ratio for prediction of left ventricular dilation: A systematic review and pooled analysis","volume":"11","author":"Loomba","year":"2015","journal-title":"Future Cardiol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1159\/000127388","article-title":"Cardiothoracic ratio, malnutrition, inflammation, and two-year mortality in non-diabetic patients on maintenance hemodialysis","volume":"31","author":"Chen","year":"2008","journal-title":"Kidney Blood Press. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1053\/j.ajkd.2016.11.026","article-title":"Cardiothoracic ratio and all-cause mortality and cardiovascular disease events in hemodialysis patients: The Q-Cohort study","volume":"70","author":"Yotsueda","year":"2017","journal-title":"Am. J. Kidney Dis."},{"key":"ref_20","first-page":"131263","article-title":"Aortic arch calcification predicts the renal function progression in patients with stage 3 to 5 chronic kidney disease","volume":"2015","author":"Li","year":"2015","journal-title":"Biomed. Res. Int."},{"key":"ref_21","first-page":"1","article-title":"Increased aortic arch calcification and cardiomegaly is associated with rapid renal progression and increased cardiovascular mortality in chronic kidney disease","volume":"9","author":"Chen","year":"2019","journal-title":"Sci. Rep."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1395","DOI":"10.1038\/ki.1997.467","article-title":"Comparison of methods to predict equilibrated Kt\/V in the HEMO Pilot Study","volume":"52","author":"Daugirdas","year":"1997","journal-title":"Kidney Int."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"958","DOI":"10.1016\/j.kint.2018.12.014","article-title":"Arterial \u201cinflammaging\u201d drives vascular calcification in children on dialysis","volume":"95","author":"Sanchis","year":"2019","journal-title":"Kidney Int."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1177\/2040622315578654","article-title":"The prevalence of vascular calcification in patients with end-stage renal disease on hemodialysis: A cross-sectional observational study","volume":"6","author":"Kraus","year":"2015","journal-title":"Ther. Adv. Chronic Dis."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1111\/j.1525-139X.2007.00259.x","article-title":"Vascular Calcification in Patients with Kidney Disease: Techniques and Technologies to Assess Vascular Calcification","volume":"20","author":"Bellasi","year":"2007","journal-title":"Semin. Dial."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1111\/sdi.12596","article-title":"Imaging for Vascular Calcification","volume":"30","author":"Raggi","year":"2017","journal-title":"Semin. Dial."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1159\/000496218","article-title":"Study on the prevalence of vascular calcification in different types of arteries and influencing factors in maintenance peritoneal Dialysis patients","volume":"47","author":"Niu","year":"2019","journal-title":"Blood Purif."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Chung, W.-S., Shih, M.-C.P., Wu, P.-Y., Huang, J.-C., Chen, S.-C., Chiu, Y.-W., Chang, J.-M., and Chen, H.-C. (2020). Progression of Aortic Arch Calcification Is Associated with Overall and Cardiovascular Mortality in Hemodialysis. Dis. Markers, 2020.","DOI":"10.1155\/2020\/6293185"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"34","DOI":"10.1159\/000360230","article-title":"Calcification of the aortic arch predicts cardiovascular and all-cause mortality in chronic hemodialysis patients","volume":"4","author":"Lee","year":"2014","journal-title":"Cardiorenal Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1620\/tjem.223.79","article-title":"Aortic arch calcification and clinical outcome in patients with end-stage renal disease","volume":"223","author":"Nitta","year":"2011","journal-title":"Tohoku J. Exp. Med."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1111\/sdi.12840","article-title":"Pathogenesis and Management of Vascular Calcification in CKD and Dialysis Patients","volume":"32","author":"Kakani","year":"2019","journal-title":"Semin. Dial."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"F891","DOI":"10.1152\/ajprenal.00163.2014","article-title":"A current understanding of vascular calcification in CKD","volume":"307","author":"Paloian","year":"2014","journal-title":"Am. J. Physiol. Ren. Physiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1554","DOI":"10.1159\/000494441","article-title":"Association between risk factors including bone-derived biomarkers and aortic arch calcification in maintenance hemodialysis patients","volume":"43","author":"Nitta","year":"2018","journal-title":"Kidney Blood Press. Res."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"206","DOI":"10.1007\/s11914-015-0270-3","article-title":"Molecular mechanisms of vascular calcification in chronic kidney disease: The link between bone and the vasculature","volume":"13","author":"Byon","year":"2015","journal-title":"Curr. Osteoporos. Rep."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1016\/j.bone.2016.11.012","article-title":"Vascular calcification in CKD-MBD: Roles for phosphate, FGF23, and Klotho","volume":"100","author":"Yamada","year":"2017","journal-title":"Bone"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1053\/j.ackd.2019.10.004","article-title":"Valvular calcification in chronic kidney disease","volume":"26","author":"Brandenburg","year":"2019","journal-title":"Adv. Chronic Kidney Dis."},{"key":"ref_37","first-page":"e18242","article-title":"Comparison of radiological findings of chest x-ray with echocardiography in determination of the heart size","volume":"17","author":"Monfared","year":"2015","journal-title":"Iran. Red. Crescent Med. J."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1016\/j.amjhyper.2004.02.012","article-title":"The chest radiograph: A useful investigation in the evaluation of hypertensive patients","volume":"17","author":"Rayner","year":"2004","journal-title":"Am. J. Hypertens."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1111\/j.1523-1755.2005.00086.x","article-title":"Clinical and pathologic characteristics of dilated cardiomyopathy in hemodialysis patients","volume":"67","author":"Aoki","year":"2005","journal-title":"Kidney Int."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"107256","DOI":"10.1016\/j.carpath.2020.107256","article-title":"Histological features of endomyocardial biopsies in patients undergoing hemodialysis: Comparison with dilated cardiomyopathy and hypertensive heart disease","volume":"49","author":"Yoshizawa","year":"2020","journal-title":"Cardiovasc. Pathol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2186","DOI":"10.1097\/01.ASN.0000135053.98172.D6","article-title":"Inflammation, residual kidney function, and cardiac hypertrophy are interrelated and combine adversely to enhance mortality and cardiovascular death risk of peritoneal dialysis patients","volume":"15","author":"Wang","year":"2004","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"557","DOI":"10.7150\/ijms.23700","article-title":"Vascular calcification and left ventricular hypertrophy in hemodialysis patients: Interrelationship and clinical impacts","volume":"15","author":"Hwang","year":"2018","journal-title":"Int. J. Med. Sci."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1291\/hypres.27.47","article-title":"Left ventricular hypertrophy is associated with arterial stiffness and vascular calcification in hemodialysis patients","volume":"27","author":"Nitta","year":"2004","journal-title":"Hypertens. Res."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1159\/000435838","article-title":"Left ventricular hypertrophy in chronic kidney disease patients: From pathophysiology to treatment","volume":"5","author":"Gorini","year":"2015","journal-title":"Cardiorenal Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1093\/ajh\/hpv128","article-title":"Association of endothelial and mild renal dysfunction with the severity of left ventricular hypertrophy in hypertensive patients","volume":"29","author":"Cao","year":"2016","journal-title":"Am. J. Hypertens."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1159\/000449452","article-title":"Intensive home hemodialysis results in regression of left ventricular hypertrophy and better clinical outcomes","volume":"44","author":"Trinh","year":"2016","journal-title":"Am. J. Nephrol."},{"key":"ref_47","first-page":"9035193","article-title":"The strategy to prevent and regress the vascular calcification in dialysis patients","volume":"2017","author":"Chen","year":"2017","journal-title":"Biomed. Res. Int."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"605","DOI":"10.1016\/j.ekir.2020.12.002","article-title":"Denosumab recovers aortic arch calcification during long-term hemodialysis","volume":"6","author":"Suzuki","year":"2020","journal-title":"Kidney Int. Rep."}],"container-title":["Journal of Personalized Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4426\/11\/7\/657\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:30:00Z","timestamp":1760164200000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4426\/11\/7\/657"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,7,13]]},"references-count":48,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2021,7]]}},"alternative-id":["jpm11070657"],"URL":"https:\/\/doi.org\/10.3390\/jpm11070657","relation":{},"ISSN":["2075-4426"],"issn-type":[{"type":"electronic","value":"2075-4426"}],"subject":[],"published":{"date-parts":[[2021,7,13]]}}}