The effect of folic acid based homocysteine lowering on cardiovascular events in people with kidney disease: Systematic review and meta-analysis

Meg J. Jardine, Amy Kang, Sophia Zoungas, Sankar D. Navaneethan, Toshiharu Ninomiya, Sagar U. Nigwekar, Martin P. Gallagher, Alan Cass, Giovanni Strippoli, Vlado Perkovic

Research output: Contribution to journalReview article

66 Citations (Scopus)

Abstract

Objective: To systematically review the effect of folic acid based homocysteine lowering on cardiovascular outcomes in people with kidney disease. Design: Systematic review and meta-analysis. Data sources: Medline, Embase, the Cochrane Library, and ClinicalTrials.gov to June 2011. Study selection: Randomised trials in people with non-dialysis dependent chronic kidney disease or end stage kidney disease or with a functioning kidney transplant reporting at least 100 patient years of follow-up and assessing the effect of folic acid based homocysteine lowering therapy. No language restrictions were applied. Data extraction: Two reviewers independently extracted data on study setting, design, and outcomes using a standardised form. The primary endpoint was cardiovascular events (myocardial infarction, stroke, and cardiovascular mortality, or as defined by study author). Secondary endpoints included the individual composite components, all cause mortality, access thrombosis, requirement for renal replacement therapy, and reported adverse events, including haematological and neurological events. The effect of folic acid based homocysteine lowering on outcomes was assessed with meta-analysis using random effects models. Results: 11 trials were identified that reported on 4389 people with chronic kidney disease, 2452 with end stage kidney disease, and 4110 with functioning kidney transplants (10 951 participants in total). Folic acid based homocysteine therapy did not prevent cardiovascular events (relative risk 0.97, 95% confidence interval 0.92 to 1.03, P=0.326) or any of the secondary outcomes. There was no evidence of heterogeneity in subgroup analyses, including those of kidney disease category, background fortification, rates of pre-existing disease, or baseline homocysteine level. The definitions of chronic kidney disease varied widely between the studies. Non-cardiovascular events could not be analysed as few studies reported these outcomes. Conclusions: Folic acid based homocysteine lowering does not reduce cardiovascular events in people with kidney disease. Folic acid based regimens should not be used for the prevention of cardiovascular events in people with kidney disease.

Original languageEnglish
Article numbere3533
JournalBMJ (Online)
Volume344
Issue number7863
DOIs
Publication statusPublished - Jun 30 2012

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Kidney Diseases
Homocysteine
Folic Acid
Meta-Analysis
Chronic Renal Insufficiency
Chronic Kidney Failure
Myocardial Infarction
Transplants
Kidney
Preexisting Condition Coverage
Renal Replacement Therapy
Mortality
Information Storage and Retrieval
Libraries
Thrombosis
Language
Outcome Assessment (Health Care)
Confidence Intervals
Therapeutics

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

The effect of folic acid based homocysteine lowering on cardiovascular events in people with kidney disease : Systematic review and meta-analysis. / Jardine, Meg J.; Kang, Amy; Zoungas, Sophia; Navaneethan, Sankar D.; Ninomiya, Toshiharu; Nigwekar, Sagar U.; Gallagher, Martin P.; Cass, Alan; Strippoli, Giovanni; Perkovic, Vlado.

In: BMJ (Online), Vol. 344, No. 7863, e3533, 30.06.2012.

Research output: Contribution to journalReview article

Jardine, MJ, Kang, A, Zoungas, S, Navaneethan, SD, Ninomiya, T, Nigwekar, SU, Gallagher, MP, Cass, A, Strippoli, G & Perkovic, V 2012, 'The effect of folic acid based homocysteine lowering on cardiovascular events in people with kidney disease: Systematic review and meta-analysis', BMJ (Online), vol. 344, no. 7863, e3533. https://doi.org/10.1136/bmj.e3533
Jardine, Meg J. ; Kang, Amy ; Zoungas, Sophia ; Navaneethan, Sankar D. ; Ninomiya, Toshiharu ; Nigwekar, Sagar U. ; Gallagher, Martin P. ; Cass, Alan ; Strippoli, Giovanni ; Perkovic, Vlado. / The effect of folic acid based homocysteine lowering on cardiovascular events in people with kidney disease : Systematic review and meta-analysis. In: BMJ (Online). 2012 ; Vol. 344, No. 7863.
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abstract = "Objective: To systematically review the effect of folic acid based homocysteine lowering on cardiovascular outcomes in people with kidney disease. Design: Systematic review and meta-analysis. Data sources: Medline, Embase, the Cochrane Library, and ClinicalTrials.gov to June 2011. Study selection: Randomised trials in people with non-dialysis dependent chronic kidney disease or end stage kidney disease or with a functioning kidney transplant reporting at least 100 patient years of follow-up and assessing the effect of folic acid based homocysteine lowering therapy. No language restrictions were applied. Data extraction: Two reviewers independently extracted data on study setting, design, and outcomes using a standardised form. The primary endpoint was cardiovascular events (myocardial infarction, stroke, and cardiovascular mortality, or as defined by study author). Secondary endpoints included the individual composite components, all cause mortality, access thrombosis, requirement for renal replacement therapy, and reported adverse events, including haematological and neurological events. The effect of folic acid based homocysteine lowering on outcomes was assessed with meta-analysis using random effects models. Results: 11 trials were identified that reported on 4389 people with chronic kidney disease, 2452 with end stage kidney disease, and 4110 with functioning kidney transplants (10 951 participants in total). Folic acid based homocysteine therapy did not prevent cardiovascular events (relative risk 0.97, 95{\%} confidence interval 0.92 to 1.03, P=0.326) or any of the secondary outcomes. There was no evidence of heterogeneity in subgroup analyses, including those of kidney disease category, background fortification, rates of pre-existing disease, or baseline homocysteine level. The definitions of chronic kidney disease varied widely between the studies. Non-cardiovascular events could not be analysed as few studies reported these outcomes. Conclusions: Folic acid based homocysteine lowering does not reduce cardiovascular events in people with kidney disease. Folic acid based regimens should not be used for the prevention of cardiovascular events in people with kidney disease.",
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AU - Navaneethan, Sankar D.

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AU - Nigwekar, Sagar U.

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AU - Strippoli, Giovanni

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N2 - Objective: To systematically review the effect of folic acid based homocysteine lowering on cardiovascular outcomes in people with kidney disease. Design: Systematic review and meta-analysis. Data sources: Medline, Embase, the Cochrane Library, and ClinicalTrials.gov to June 2011. Study selection: Randomised trials in people with non-dialysis dependent chronic kidney disease or end stage kidney disease or with a functioning kidney transplant reporting at least 100 patient years of follow-up and assessing the effect of folic acid based homocysteine lowering therapy. No language restrictions were applied. Data extraction: Two reviewers independently extracted data on study setting, design, and outcomes using a standardised form. The primary endpoint was cardiovascular events (myocardial infarction, stroke, and cardiovascular mortality, or as defined by study author). Secondary endpoints included the individual composite components, all cause mortality, access thrombosis, requirement for renal replacement therapy, and reported adverse events, including haematological and neurological events. The effect of folic acid based homocysteine lowering on outcomes was assessed with meta-analysis using random effects models. Results: 11 trials were identified that reported on 4389 people with chronic kidney disease, 2452 with end stage kidney disease, and 4110 with functioning kidney transplants (10 951 participants in total). Folic acid based homocysteine therapy did not prevent cardiovascular events (relative risk 0.97, 95% confidence interval 0.92 to 1.03, P=0.326) or any of the secondary outcomes. There was no evidence of heterogeneity in subgroup analyses, including those of kidney disease category, background fortification, rates of pre-existing disease, or baseline homocysteine level. The definitions of chronic kidney disease varied widely between the studies. Non-cardiovascular events could not be analysed as few studies reported these outcomes. Conclusions: Folic acid based homocysteine lowering does not reduce cardiovascular events in people with kidney disease. Folic acid based regimens should not be used for the prevention of cardiovascular events in people with kidney disease.

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