1,721,007 research outputs found
Treatment Options for Proliferative Lupus Nephritis An Update of Clinical Trial Evidence
No full textSystemic lupus erythematosus involves the kidney in up to 60% of patients, and if untreated, may result in complete loss of kidney function. In this article, we review meta-analyses and clinical trial data on the therapeutic options for proliferative lupus nephritis, and complete a meta-analysis of the use of mycophenolate mofetil (MMF) compared with cyclophosphamide-based regimens. Clinical trials have found that cyclophosphamide-based regimens result in a decreased risk of end-stage renal disease, but are associated with significant toxicity in lupus nephritis. Even though the survival advantage of the US National Institutes of Health and Euro-Lupus regimens based on intravenous and oral cyclophosphamide has not been established, these approaches are broadly adopted in proliferative lupus nephritis. Recent studies have confirmed the therapeutic equivalence and potential comparative superiority of MMF and cyclophosphamide in induction of remission in patients with lupus nephritis. Use of MMF resulted in a lower incidence of infection and loss of gonadal function compared with cyclophosphamide regimens. Cyclophosphamide plus corticosteroids could represent the induction agents of choice in patients with severe lupus nephritis, whereas MMF could be used as an induction agent in patients with mild disease, patients who wish to preserve fertility and those at high risk of infections. However, given the complexity of disease activity in patients with lupus nephritis, the initial treatment options need to be individualized and altered based on the subsequent treatment response. Ongoing clinical trials will provide further evidence. © 2008 Adis Data Information BV. All rights reserved
Haemoglobin and haematocrit targets for the anaemia of chronic kidney disease
No full textBACKGROUND: Anaemia affects 60% to 80% of patients with chronic kidney disease (CKD) reduces quality of life and is a risk factor for early death. Treatment options are blood transfusion, erythropoietin (EPO) and darbepoetin alfa. Recently higher haemoglobin (Hb) and haematocrit (HCT) targets have been widely advocated because of positive associations with improved survival and quality of life from observational studies. OBJECTIVES: To assess the benefits and harms of different Hb or HCT targets in CKD patients receiving any treatment for anaemia. SEARCH STRATEGY: We searched The Cochrane Renal Group's specialised register, Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library) MEDLINE (from 1966), EMBASE (from 1980) and reference lists of retrieved articles.Date of most recent search: April 2006 SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs comparing different Hb/HCT targets in patients with the anaemia of CKD. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and results expressed as relative risks (RR) for dichotomous outcomes and weighted mean difference (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS: Twenty two trials (3707 patients) were included. Hb > or = 133 g/L was not associated with a reduction in the risk of all-cause mortality compared with 120 g/L in dialysis and pre-dialysis patients. In pre-dialysis patients, there was a significantly lower end of treatment creatinine clearance with Hb < 120 g/L compared to > 130 g/L (MD -4.17, 95% CI -6.33 to -2.02) but no significant difference in the risk of end-stage kidney disease (ESKD) (RR 1.05, 95% CI 0.50 to 2.22). Lower Hb targets resulted in an increased risk for seizures (RR 5.25, 95% CI 1.13 to 24.34) and a reduced risk of hypertensive episodes (RR 0.50, 95% CI 0.33 to 0.76). There were no significant differences in the risk of vascular access thrombosis. AUTHORS' CONCLUSIONS: There was no significant difference in the risk of death for low (< 120 g/L) versus higher Hb targets (>133 g/L). Lower Hb targets were significantly associated with an increased risk for seizures but a reduced risk of hypertension. In general study quality was poor. There is a need for more adequately powered, well-designed and reported trials. Trials should be pragmatic, focusing on hard end-points (mortality, ESKD, major side effects) or outcomes which were previously not studied adequately (e.g. seizures, quality of life)
Role of statins in preventing adverse cardiovascular outcomes in patients with chronic kidney disease
No full textPurpose of review
Cardiovascular disease accounts for the majority of deaths in chronic kidney disease (CKD). Dyslipidemia is a well established cardiovascular risk factor. We summarize key aspects of available evidence relating to beneficial effects of statins in nondialysis-dependent CKD, dialysis-dependent CKD and renal transplant recipients.
Recent findings
Previous trials and their meta-analyses suggested that statins reduce lipid levels, the risk of cardiovascular disease and all-cause mortality in nondialysis-dependent CKD. The Study of Heart and Renal Protection (SHARP) study that enrolled both dialysis-dependent and nondialysis-dependent CKD patients showed a 17% decrease in major atherosclerotic events with statins or ezetimibe. Similar cardiovascular benefits are observed in renal transplant recipients. However, such positive effects were not found in two recent clinical trials that enrolled hemodialysis patients alone. This lack of benefit might be attributed to differences in the cause of cardiovascular death seen in dialysis patients and smaller sample size. The overall benefits-harms tradeoff may benefit from meta-analysis and individual patient data meta-analysis in hemodialysis patients including the SHARP data.
Summary
Nondialysis-dependent CKD patients and renal transplant recipients benefit from statins. Statins have also been found to be beneficial in one of the three large trials in hemodialysis patients, a matter which may be further explored
How to read a nephrology systematic review
No full textA systematic review provides the best summary of evidence for clinical decision-making in nephrology by summarizing all the primary studies that evaluate a specific clinical question. By using rigorous and pre-specified methods, conclusions about the overall effect of an intervention can be more reliable, precise and comprehensive in a systematic review than those derived from individual studies. In this article, we describe the key components of a systematic review and meta-analysis. We summarize the features of a systematic review that should be looked for when considering the accuracy and validity of its results - particularly when applying the outcomes of a systematic review to a clinical question. © 2010 Asian Pacific Society of Nephrology
Sevelamer hydrochloride versus calcium salts as phosphate binder in chronic kidney disease: A systematic review
No full textEvidence for optimal hemoglobin targets in chronic kidney disease
No full textEven though anemia occurs frequently in patients with chronic kidney disease and therapeutic options are widely available, the ideal hemoglobin target level is not clearly established. We start from 2 anecdotes and review the evidence in favor of and against higher (> 12 g/dL) and normal hemoglobin targets as compared to subnormal or low hemoglobin levels in different subsets of chronic kidney disease (either predialysis or dialysis). Current clinical trials and their systematic reviews have found that higher hemoglobin levels (> 12 g/dL) do not significantly impact on patient-level cardiovascular end points including cardiovascular and all-cause mortality. Patients feel better, and enhanced quality of life parameters have been identified in most short-term studies when higher hemoglobin levels are achieved. However, achieving and maintaining higher hemoglobin levels carry the risk of hypertension and vascular access thrombosis in dialysis patients and are costly. In addition, a potential for increased risk of death (or no benefit at most) with higher Hb levels has been found in patients with severe cardiac disease in a larger trial. Benefits of and harm from hemoglobin targets should be carefully weighed, and certainly more, proper studies are needed before higher hemoglobin levels (> 12 g/dL) are widely adopted in these high-risk patients
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