The severity and predictors of abdominal aortic calcification among hemodialysis patients: a cross-sectional study from Palestine

Abstract Abdominal aortic calcification (AAC) is a clinically important marker of systemic vascular disease and cardiovascular risk in patients receiving maintenance hemodialysis. Evidence from Palestine remains limited. This study assessed the prevalence and severity of AAC and identified factors associated with increasing calcification burden among Palestinian hemodialysis patients. This single-center cross-sectional study was conducted at An-Najah National University Hospital, Palestine, between August 2025 and January 2026. Adults receiving maintenance hemodialysis for at least 6 months were recruited using convenience sampling. AAC was assessed on lateral lumbar radiographs using the validated 24-point Kauppila score and categorized as no calcification (0), mild-to-moderate calcification (1–6), or severe calcification (≥ 7). Clinical, laboratory, medication, and radiographic data were analyzed using appropriate parametric and non-parametric tests. A multivariable ordinal logistic regression model was used to identify independent predictors of increasing AAC severity, and a sensitivity model additionally adjusted for serum calcium and phosphate. A total of 163 patients were included, representing 95.9% of the prespecified target sample. Overall, 35.6% had no calcification, 23.9% had mild-to-moderate calcification, and 40.5% had severe AAC. Age was progressively higher across AAC categories (p < 0.001) and showed a moderate positive correlation with the total AAC score (Spearman’s ρ = 0.531, p < 0.001). Serum albumin, creatinine, fasting glucose, potassium, and platelet count were associated with AAC in unadjusted group comparisons or correlation analyses. In the primary multivariable model, age was the only independent predictor of increasing AAC severity; each additional year of age was associated with a 7.9% increase in the odds of belonging to a higher AAC category (adjusted OR 1.079, 95% CI 1.049–1.108; p < 0.001). The proportional-odds assumption was satisfied ( p = 0.620), and model fit was acceptable. In the chronic kidney disease–mineral and bone disorder (CKD-MBD) sensitivity analysis, age remained significant (adjusted OR 1.082, 95% CI 1.051–1.114; p < 0.001), whereas serum phosphate was not significant and serum calcium showed only a borderline association. Associations involving diabetes and albumin were sensitive to model specification and were therefore interpreted cautiously. AAC was highly prevalent in this Palestinian hemodialysis cohort, with severe calcification affecting approximately two in five patients. Age was the most robust and consistently significant predictor of increasing AAC severity. Lateral lumbar radiography may provide an accessible adjunct to cardiovascular risk assessment, although prospective multicenter studies are needed to confirm clinical utility and clarify modifiable risk pathways.