Chronic kidney disease (CKD) is a major global public health problem, affecting 10–13% of the world's population. As kidney function progressively declines, disturbances in mineral metabolism, chronic inflammation, oxidative stress, and accumulation of uraemic toxins cause accelerated cardiovascular disease (CVD), which remains the leading cause of morbidity and mortality among patients receiving maintenance haemodialysis (MHD). Cardiovascular mortality among dialysis patients is higher, and vascular calcification plays central pathogenic role.1 Vascular calcification (VC) is a common complication in patients with end-stage kidney disease (ESKD) undergoing maintenance haemodialysis. VC is as an active, cell-mediated process resembling bone formation,2 in which vascular smooth muscle cells undergo osteogenic transformation under the affect of hyperphosphataemia, calcium overload, secondary hyperparathyroidism, chronic inflammation, oxidative stress, and deficiency of calcification inhibitors like fetuin-A and matrix Gla protein. These pathological changes cause calcium-phosphate deposition within intimal and medial layers of blood vessels. This causes increased arterial stiffness, left ventricular hypertrophy, impaired coronary perfusion, and heightened cardiovascular risk. Dialysis vintage, defined as the duration of exposure to haemodialysis, is an important determinant of vascular calcification. Prolonged dialysis treatment is associated with cumulative exposure to mineral and bone disorders, chronic inflammation, recurrent calcium loading from phosphate binders or dialysate, and persistent metabolic abnormalities. All these accelerate vascular calcification. Increasing prevalence and severity of vascular calcification are associated with longer dialysis duration, but the relationship can be affected by age, diabetes mellitus, serum phosphate, calcium-phosphate product, parathyroid hormone levels, nutritional status, and dialysis adequacy also.3 Accurate assessment of vascular calcification is important for cardiovascular risk stratification in patients with ESKD. Computed tomography (CT)-based coronary artery calcium scoring is considered the gold standard for quantifying vascular calcification,but its widespread use is limited by cost, radiation exposure, and availability. So simple radiographic methods like Adragão score using plain radiographs of the pelvis and hands and Kauppila abdominal aortic calcification score using lateral lumbar radiographs have gained popularity because they are inexpensive, reproducible, and recommended by Kidney Disease:4 Improving Global Outcomes (KDIGO) guidelines for clinical risk assessment. These radiographic scores have shown good correlation with CT-based measurements and independently predict cardiovascular events and mortality among dialysis patients. In spite of increasing evidence regarding vascular calcification in haemodialysis populations, relatively few studies have evaluated the independent association between dialysis vintage and radiographic vascular calcification burden after adjustment for traditional and CKD-specific cardiovascular risk factors. Also data from the Indian haemodialysis population is limited. Understanding the relationship between dialysis duration and vascular calcification may facilitate early identification of high-risk individuals and guide interventions targeting CKD-mineral and bone disorder (CKD-MBD) to reduce cardiovascular complications.5 AIM AND OBJECTIVES: AIM To evaluate the association between dialysis vintage and radiographic vascular calcification burden among patients undergoing maintenance haemodialysis. Objectives 1. To determine the prevalence and severity of radiographic vascular calcification among maintenance haemodialysis patients. 2. To evaluate the association of radiographic vascular calcification with selected demographic and clinical factors.

Study Design This was hospital-based cross-sectional analytical study Study Setting The study was done in the Department of Nephrology at a NRI Medical College, Chinakakani, Andhra Pradesh. Study Duration The study was done for 4 months from November 2025 to March 2026. Study Population The study population included patients with end-stage kidney disease (ESKD) undergoing maintenance haemodialysis at the study centre. Sample Size: 100 Inclusion Criteria 1. Patients aged ≥18 years. 2. Patients diagnosed with end-stage kidney disease receiving maintenance haemodialysis. 3. Patients on haemodialysis for a minimum duration of 3 months. 4. Patients who provided written informed consent. Exclusion Criteria 1. Acute kidney injury requiring temporary dialysis. 2. Previous kidney transplantation. 3. Active infection, malignancy, or severe inflammatory conditions. 4. Recent major cardiovascular events (such as myocardial infarction or stroke) within the specified study period. 5. Pregnancy. Procedure Demographic and clinical details like age, sex, duration of chronic kidney disease, dialysis vintage, and history of diabetes mellitus and hypertension, were recorded from the patients' medical records and through direct interview. Relevant laboratory parameters like serum calcium, serum phosphate, calcium–phosphate product, and intact parathyroid hormone (iPTH) levels, were obtained from routine investigations. Radiographic vascular calcification was assessed using plain radiographs of the pelvis and hands (Adragão score) and/or lateral abdominal radiographs (Kauppila score). The severity of vascular calcification was graded according to the respective scoring system, and patients were categorized based on the extent of calcification for subsequent statistical analysis. Statistical Analysis Categorical variables were expressed as frequencies and percentages and analysed using the Chi-square test. A p value <0.05 was considered statistically significant. Ethical Considerations Written informed consent was obtained from all patients before participation. Confidentiality of patient information was maintained throughout the study.

Prevalence of Radiographic Vascular Calcification: 58% of the patients had radiographic vascular calcification Table 1: Prevalence of radiographic vascular calcification Radiographic Vascular Calcification Status Number of Patients Percentage (%) Present 58 58% Absent 42 42% Total 100 100% Distribution of Vascular Calcification Severity Based on Radiographic Scoring: 38% of the patients mild calcification. Distribution of Patients According to Dialysis Vintage: 40% of the patients had <2 years dialysis vintage. Associations with vascular calcification: Table 2. Association Between Age Group and Radiographic Vascular Calcification Age group (years) No Calcification Mild Moderate Severe p value <40 18 5 1 0 0.002 40–59 16 18 4 2 ≥60 8 15 7 6 Total 42 38 12 8 Increasing age was significantly associated with higher vascular calcification burden. Table 3. Association Between Dialysis Vintage and Vascular Calcification Dialysis Vintage No Calcification Mild Moderate Severe p value <2 years 25 5 0 0 <0.001 2–5 years 14 18 5 1 >5 years 3 15 7 7 Total 42 38 12 8 Patients with longer dialysis vintage had significantly greater vascular calcification severi Diabetes mellitus, hyperphosphataemia, and elevated iPTH levels were significantly associated with moderate-to-severe vascular calcification. Table 4. Association of Clinical and Biochemical Factors with Moderate-to-Severe Vascular Calcification Variable Mild/No VC (n = 80) Moderate/Severe VC (n = 20) p value Diabetes mellitus, n (%) 28 (35.0) 14 (70.0) 0.004 Hyperphosphataemia (Serum phosphate >5.5 mg/dL), n (%) 24 (30.0) 15 (75.0) <0.001 Elevated iPTH (>300 pg/mL), n (%) 22 (27.5) 14 (70.0) <0.001 Table 5. Multivariable Logistic Regression Analysis Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval p value Age ≥60 years 3.18 1.35–7.48 0.008 Dialysis vintage >5 years 4.12 1.71–9.94 0.002 Diabetes mellitus 2.56 1.08–6.05 0.033 Hyperphosphataemia 3.01 1.23–7.37 0.016 Elevated iPTH (>300 pg/mL) 2.89 1.16–7.17 0.022 Multivariable logistic regression analysis showed that age (≥60 years), prolonged dialysis vintage (>5 years), diabetes mellitus, hyperphosphataemia, and elevated intact parathyroid hormone (iPTH) levels were independent predictors of moderate-to-severe radiographic vascular calcification. Patients aged ≥60 years had 3.18 times higher odds of moderate-to-severe vascular calcification (AOR 3.18, 95% CI: 1.35–7.48, p = 0.008). Dialysis vintage >5 years was the strongest independent predictor (AOR 4.12, 95% CI: 1.71–9.94, p = 0.002). Diabetes mellitus (AOR 2.56, 95% CI: 1.08–6.05, p = 0.033), hyperphosphataemia (AOR 3.01, 95% CI: 1.23–7.37, p = 0.016), and elevated iPTH levels (AOR 2.89, 95% CI: 1.16–7.17, p = 0.022) were also independently associated with an increased burden of radiographic vascular calcification.

The present study assessed the prevalence, severity, and determinants of radiographic vascular calcification among patients undergoing maintenance haemodialysis. Vascular calcification is a common complication of chronic kidney disease (CKD), particularly in patients receiving long-term haemodialysis, and is associated with increased cardiovascular morbidity and mortality.¹ In the present study, radiographic vascular calcification was observed in 58% of patients undergoing maintenance haemodialysis, 42% had no evidence of calcification. This finding is comparable with that reported by Adragão et al¹, who showed vascular calcification in 74% of haemodialysis patients using a simple radiographic scoring system. Blacher et al³ reported a high prevalence of arterial calcification among patients with end-stage renal disease and showed its association with arterial stiffness and cardiovascular risk. The comparable prevalence observed across these studies confirms that vascular calcification is highly prevalent among patients receiving maintenance haemodialysis. With regard to severity, 38% of patients had mild vascular calcification, 12% had moderate calcification, 8% had severe calcification, and 42% had no calcification. Similar observations have been reported by Adragão et al.¹, in whom mild-to-moderate vascular calcification was more common than severe disease. The predominance of mild and moderate calcification in the present study may inform differences in patient characteristics like age, dialysis duration, diabetic status, and management of CKD-mineral and bone disorder (CKD-MBD). Increasing age showed a significant association with greater vascular calcification burden in the present study. Patients aged ≥60 years showed higher calcification severity than younger patients, and multivariable logistic regression identified advanced age as an independent predictor of moderate-to-severe vascular calcification. These findings are similar with those of Adragão et al¹ and Blacher et al³, who identified advancing age as an important determinant of vascular calcification in patients with end-stage kidney disease. Age-related arterial stiffening, endothelial dysfunction, and prolonged exposure to cardiovascular risk factors may contribute to progressive vascular calcification. Dialysis vintage was also significantly associated with vascular calcification severity. Patients undergoing haemodialysis for more than five years showed more calcification burden than those with shorter dialysis duration. Prolonged dialysis vintage is the strongest independent predictor of moderate-to-severe vascular calcification on multivariable analysis. These findings are in agreement with those reported by Jean et al.² and Nitta et al⁶, who showed that prolonged haemodialysis duration is associated with progressive vascular calcification and adverse cardiovascular outcomes in patients receiving maintenance haemodialysis. Diabetes mellitus was significantly associated with moderate-to-severe vascular calcification in the present study and remained an independent predictor on multivariable analysis. Similar findings have been reported by Jean et al.² and Nitta et al.⁶, who identified diabetes mellitus as an important determinant of vascular calcification in haemodialysis patients. Chronic hyperglycaemia promotes endothelial dysfunction, oxidative stress, inflammation, and osteogenic transformation of vascular smooth muscle cells, thereby accelerating vascular calcification. Hyperphosphataemia and elevated intact parathyroid hormone (iPTH) levels were also significantly associated with increased vascular calcification burden and remained independent predictors after multivariable adjustment. These findings are consistent with the observations of Moe and Chen⁴, who described disturbances in mineral metabolism as central mechanisms in the pathogenesis of vascular calcification in CKD. Ketteler et al.⁵ showed that abnormalities in calcification regulatory pathways contribute to increased cardiovascular mortality among patients receiving dialysis. Overall, the findings of the present study are consistent with previously published literature and confirm that radiographic vascular calcification is highly prevalent among patients undergoing maintenance haemodialysis. Advanced age, prolonged dialysis vintage, diabetes mellitus, hyperphosphataemia, and elevated iPTH levels were identified as significant determinants of vascular calcification burden. Plain radiographic assessment offers a simple, inexpensive, and readily available method for evaluating vascular calcification and may facilitate early identification of haemodialysis patients at increased cardiovascular risk, particularly in resource-limited settings.¹˒⁷˒⁸

Radiographic vascular calcification was highly prevalent among patients undergoing maintenance haemodialysis. Increasing age and prolonged dialysis vintage were significantly associated with greater vascular calcification burden, while diabetes mellitus, hyperphosphataemia, and elevated intact parathyroid hormone levels were independent predictors of moderate-to-severe vascular calcification. These findings indicate that plain radiographic assessment is a simple, inexpensive, and practical method for evaluating vascular calcification in maintenance haemodialysis patients and may aid in the early identification of patients at increased cardiovascular risk, allowing timely implementation of appropriate preventive and therapeutic strategies.

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