Association of non-invasive measures of subclinical atherosclerosis and arterial stiffness with mortality and major cardiovascular events in chronic kidney disease: systematic review and meta-analysis of cohort studies

Abstract Background Non-invasive cardiovascular disease (CVD) risk prediction, in subclinical stages, aiming to stratify patients and tailor interventions remains an unmet need in chronic kidney disease (CKD). In this meta-analysis, we summarize the association of carotid intima–media thickness (cIMT), coronary artery calcium score (CACS) and pulse wave velocity (PWV) with all-cause mortality, cardiovascular (CV) mortality and CV events in non-dialysis CKD and patients on haemodialysis. Methods Systematic review and meta-analysis of prospective cohort studies. Results Out of 27 984 records, a total of 45 studies were eligible for quantitative synthesis; 11 for cIMT, 18 for CACS and 16 for PWV involving 2235, 4904 and 5717 patients, respectively. Meta-analysis was possible from pooled data of five cIMT studies (708 subjects), eight CACS studies (862 subjects) and nine PWV studies (1508 subjects). In dialysis patients, cIMT was associated with all-cause mortality [relative risk (RR) per unit increase: 1.08, 95% confidence interval (CI) 1.00–1.17, I2: 68%] and CV mortality (RR: 1.29, 95% CI 1.14–1.47, I2: 0%). High versus low CACS was associated with all-cause mortality (RR: 2.51, 95% CI 1.66–3.79, I2: 5.7%) and CV events (RR: 3.77 95% CI 2.16–6.58, I2: 20.2%). High versus low PWV was associated with all-cause (RR: 5.34, 95% CI 3.01–9.47, I2: 0%) and CV mortality (RR: 8.55, 95% CI 4.37–16.73, I2: 0%). The combined estimated for all-cause mortality per 1 m/s increment unit in PWV was 1.25 (95% CI 1.17–1.34, I2: 0%) and for CV mortality was 1.24 (95% CI 1.16–1.34, I2: 15.5%). In non-dialysis patients, CACS was associated with CV events (RR: 4.02, 95% CI 1.57–10.29, I2: 63.4%). High versus low PWV was associated with all-cause mortality (RR: 2.52, 95% CI 1.40–4.55, I2: 62.6%). Conclusions Non-invasive measures of atherosclerosis and arterial stiffening are associated with all-cause and CV mortality as well as CV events among patients with all stages of CKD. These markers could be considered for the evaluation of CV morbidity and mortality risks. Moreover, the results of this meta-analysis support the study of interventions, with effect on these markers of vascular disease, on long-term CVD outcomes.

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Comparison between Intravenous Iron and Oral Iron Preparations for the Treatment of Anemia of Chronic Kidney Disease - A Systematic Review and Meta-Analysis

Blood ◽

10.1182/blood.v110.11.3748.3748 ◽

2007 ◽

Vol 110 (11) ◽

pp. 3748-3748

Author(s):

Anat Gafter-Gvili ◽

Benaya Rozen-Zvi ◽

Mical Paul ◽

Leonard Leibovici ◽

Gafter Uzi ◽

...

Keyword(s):

Systematic Review ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Meta Analysis ◽

Oral Iron ◽

Dialysis Patients ◽

Significant Difference ◽

All Cause Mortality ◽

Iron Preparation ◽

Iv Iron

Abstract Background: There is confounding data regarding the best method of iron supplementation in chronic kidney disease (CKD), without a consistent approach in clinical practice. Objectives: To evaluate the efficacy and safety of intravenous (IV) iron versus oral iron in patients treated for anemia of CKD. Methods: Systematic review and meta-analysis of randomized controlled trials comparing IV iron preparation with oral iron preparation for the treatment of anemia in patients with CKD (stage III, IV and V). The Cochrane Library, MEDLINE, conference proceedings and references were searched until 2007. Primary outcomes: absolute hemoglobin (Hb) level or change in Hb level from baseline at two months or at end of study; all-cause mortality. Secondary outcomes: need for renal replacement therapy (RRT) in predialysis patient and adverse events. Weighted mean differences (WMD) for outcomes with continuous variables and relative risks (RR) for dichotomous outcomes with 95% confidence intervals (CI) were estimated and pooled. Results: Our search yielded 11 trials which compared IV iron preparations (iron sucrose, iron gluconate or iron dextran) to oral iron. Compared to oral iron, there was a significant rise in Hb level in the IV iron treated hemodialysis patients (WMD 1.17; 95%CI 0.19–2.15, fig). Significant heterogeneity was observed due to different baseline Hb values and baseline iron status, different dosages of oral iron, and different dosages of erythropoiesis stimulating agents (ESA). For predialysis patients, there was a small but significant difference in the Hb level favoring the IV iron group (WMD 0.28; 95% CI 0.15–0.4, fig). For both groups effect estimates were not influenced by ESA administration. In predialysis patients, there was no significant difference in the risk for requiring RRT during the trial between the different groups (RR 0.63; 95%CI 0.25–1.65). Data on all-cause mortality were sparse (RR 0.54; 95%CI 0.09–3.13, 3 trials) and there was no difference in adverse events (RR 0.9; 95%CI 0.65–1.24) between the IV and oral treated patients. However, discontinuations of treatment were more common (RR 3.27; 95%CI 1.15–9.26) for the IV iron treated patients. Conclusions: Our review demonstrates that dialysis patients treated with IV iron have better Hb response than patients treated with oral iron. For predialysis patients, this effect is very small. IV iron should be preferred in the treatment of anemia in dialysis patients. In predialysis patients the slight advantage in Hb response should be weighed against the inconvenience and cost of IV iron treatment.

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