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Miao Y, Guo Y, Chen Y, Lin Y, Lu Y, Guo Q. The effect of B-vitamins on the prevention and treatment of cardiovascular diseases: a systematic review and meta-analysis. Nutr Rev 2023:nuad127. [PMID: 37850302 DOI: 10.1093/nutrit/nuad127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023] Open
Abstract
CONTEXT Previous research evaluating the effects in B-vitamins on the prevention and treatment of cardiovascular disease (CVD) has substantial limitations and lacks recently published large prospective studies; hence, conducting an updated meta-analysis is needed. OBJECTIVE We investigated the association between vitamin B status and human CVD development in order to provide more specific advice about vitamin B intake for those at risk of CVD. DATA SOURCES Relevant articles were identified by JSTOR, PubMed, and ProQuest databases. DATA EXTRACTION Key words used to identify the studies included the different combinations of B-vitamins, folate, folic acid, vitamin B6, vitamin B12, homocysteine, cardiovascular disease, stroke, coronary disease, myocardial infarction, and cerebrovascular and transient ischemic attack. The database search was supplemented by hand-searching of reference lists of selected articles. DATA ANALYSIS Pooled estimates were calculated from the mean differences using a random-effects model. RESULTS Supplementation with folic acid was reported to have a clinical benefit of significantly reducing carotid intima-media thickness. Higher intakes of folic acid, vitamin B6, and vitamin B12 were generally associated with a lower risk of CVD in the general population, except in those without normal renal function and those with unstable angina or past non-ST-elevation myocardial infarction. CONCLUSION Vitamin B supplementation resulted in the greatest cardiovascular benefit in those with normal renal function and without unstable angina or non-ST-elevation myocardial infarction recently. Factors such as age, gender, and genetic polymorphisms contribute to varying effects.
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Affiliation(s)
- Ya Miao
- Department of Geriatrics, Shanghai Sixth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yihan Guo
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Yixin Chen
- Department of Geriatrics, Shanghai Sixth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijia Lin
- Department of Geriatrics, Shanghai Sixth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Lu
- Department of Geriatrics, Shanghai Sixth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qihao Guo
- Department of Geriatrics, Shanghai Sixth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
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2
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ALSolami AA, Almalki AA, Alhedyan SY, Alghamdi A, Alzahrani SM, Dause WR, Hamdi FA, Howladar MT, Ibrahim IA. Plasma Homocysteine Levels and Cardiovascular Events in Patients With End-Stage Renal Disease: A Systematic Review. Cureus 2023; 15:e40357. [PMID: 37456428 PMCID: PMC10339662 DOI: 10.7759/cureus.40357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Patients with chronic renal disease or failure are at a heightened risk of mortality due to cardiovascular disease (CVD), which is a predominant cause of death in this population. Hyperhomocysteinemia is prevalent in patients with end-stage renal disease (ESRD), which may increase their susceptibility to CVD. METHODS We conducted a comprehensive search of PubMed, Science Direct, and Google Scholar for articles published between 2003 and February 2023, using a combination of keywords such as "plasma homocysteine levels," "hyperhomocysteinemia," "end-stage renal disease," "renal failure," "kidney failure," "cardiovascular events," "cardiovascular disease," "myocardial infarction," "coronary artery disease," and "stroke." Our inclusion criteria were studies that investigated the association between total homocysteine (Hcy) level and CVD or total mortality, as well as the impact of vitamin supplementation on cardiovascular or mortality risk. We restricted our search to English-language studies that included ESRD patients and provided data on plasma Hcy levels and associated CVD events. RESULTS This systematic review includes 11 articles published between 2003 and 2023 that enrolled a total of 3,953 subjects, of whom 79.15% were male patients. All studies included in the review were either quantitative randomized trials or non-randomized studies, such as cross-sectional, cohort, or case-control studies. Of the total studies included, 10 reported either cardiovascular mortality or CVD events, including cardiovascular death, myocardial infarction (MI), angina, and stroke. One study reported the CVD risk score of the patients, and most of them had higher total homocysteine (tHcy) levels. Overall, a total of 817 CVD events were reported across the studies. CONCLUSION In conclusion, the relationship between Hcy and cardiovascular events in ESRD patients is not straightforward and requires further research. However, our review suggests that Hcy could be a predictor of cardiovascular events in this population, and its nutritional characteristics as well as other associated comorbidities may contribute to its inverse association with outcomes.
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Affiliation(s)
| | | | | | | | | | - Wesam R Dause
- Cardiology, King Fahad Armed Forces Hospital, Jeddah, SAU
| | - Fahad A Hamdi
- Cardiology, King Fahad Armed Forces Hospital, Jeddah, SAU
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3
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Nutritional Approaches to Modulate Cardiovascular Disease Risk in Systemic Lupus Erythematosus: A Literature Review. Nutrients 2023; 15:nu15041036. [PMID: 36839394 PMCID: PMC9958972 DOI: 10.3390/nu15041036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic pathology characterized by a bimodal mortality pattern attributed to clinical disease activity and cardiovascular disease (CVD). A complex interaction between traditional CVD risk factors such as obesity, dyslipidemia, smoking, insulin resistance, metabolic syndrome, and hypertension, as well as the presence of non-traditional CVD risk factors such as hyperhomocysteinemia, pro-inflammatory cytokines, and C-reactive protein levels, has been suggested as a cause of the high prevalence of CVD in SLE patients. On the other hand, environmental factors, such as nutritional status, could influence the disease's prognosis; several nutrients have immunomodulators, antioxidants, and anti-cardiometabolic risk properties which could reduce SLE severity and organ damage by decreasing the development of traditional and non-traditional CVD risk factors. Therefore, this critical literature review discusses the therapeutic potential of nutritional approaches that could modulate the development of the main comorbidities related to CVD risk in SLE patients.
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4
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Jenkins DJA, Spence JD, Giovannucci EL, Kim YI, Josse RG, Vieth R, Sahye-Pudaruth S, Paquette M, Patel D, Blanco Mejia S, Viguiliouk E, Nishi SK, Kavanagh M, Tsirakis T, Kendall CWC, Pichika SC, Sievenpiper JL. Supplemental Vitamins and Minerals for Cardiovascular Disease Prevention and Treatment: JACC Focus Seminar. J Am Coll Cardiol 2021; 77:423-436. [PMID: 33509399 DOI: 10.1016/j.jacc.2020.09.619] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
This is an update of the previous 2018 systematic review and meta-analysis of vitamin and mineral supplementation on cardiovascular disease outcomes and all-cause mortality. New randomized controlled trials and meta-analyses were identified by searching the Cochrane library, Medline, and Embase, and data were analyzed using random effects models and classified by the Grading of Recommendations Assessment Development and Evaluation approach. This updated review shows similar findings to the previous report for preventive benefits from both folic acid and B vitamins for stroke and has been graded with moderate quality. No effect was seen for the commonly used multivitamins, vitamin D, calcium, and vitamin C, and an increased risk was seen with niacin (with statin) for all-cause mortality. Conclusive evidence for the benefit of supplements across different dietary backgrounds, when the nutrient is sufficient, has not been demonstrated.
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Affiliation(s)
- David J A Jenkins
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, St. Michael's Hospital, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, Ontario, Canada.
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Edward L Giovannucci
- Departments of Nutrition and Epidemiology, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Young-In Kim
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Robert G Josse
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Reinhold Vieth
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sandhya Sahye-Pudaruth
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Melanie Paquette
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Darshna Patel
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Sonia Blanco Mejia
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, St. Michael's Hospital, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Effie Viguiliouk
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, St. Michael's Hospital, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Stephanie K Nishi
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, St. Michael's Hospital, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Meaghan Kavanagh
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tom Tsirakis
- Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Cyril W C Kendall
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, St. Michael's Hospital, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada; College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Canada
| | - Sathish C Pichika
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Mathematics and Statistics, University of Windsor, Windsor, Ontario, Canada
| | - John L Sievenpiper
- Department of Nutritional Sciences, Temerty, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, St. Michael's Hospital, Toronto, Ontario, Canada; Clinical Nutrition Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, Ontario, Canada
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5
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Badri S, Vahdat S, Seirafian S, Pourfarzam M, Gholipur-Shahraki T, Ataei S. Homocysteine-Lowering Interventions in Chronic Kidney Disease. J Res Pharm Pract 2021; 10:114-124. [PMID: 35198504 PMCID: PMC8809459 DOI: 10.4103/jrpp.jrpp_75_21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 09/25/2021] [Indexed: 12/20/2022] Open
Abstract
The incidence of cardiovascular events and mortality is higher in patients with chronic kidney disease (CKD) compared to the general population. Homocysteine (Hcy) appears to be an independent risk factor for cardiovascular diseases in general populations and patients with CKD. Further, hyperhomocysteinemia can cause endothelial damage and increase the activity and production of coagulation factors, and its prevalence among patients with end-stage renal disease is approximately 85%-100%. Most treatments, which lower Hcy levels and have been considered in previous studies, include folic acid, B vitamins, omega-3 fatty acids, and N-acetylcysteine. However, the effect of therapies that can decrease Hcy levels and thus cardiovascular events in these patients is still unclear. The results are conflicting and require further investigation. To guide treatment decisions and improve patient outcomes, multiple databases were searched, including Web of Science, PubMed, and Medline to summarize the available evidence (i.e., clinical trial and meta-analyses) on Hcy-lowering interventions and cardiovascular events.
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Affiliation(s)
- Shirinsadat Badri
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran.,Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sahar Vahdat
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shiva Seirafian
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Morteza Pourfarzam
- Department of Clinical Biochemistry, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Tahereh Gholipur-Shahraki
- Department of Clinical Pharmacy and Pharmacy Practice, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Sara Ataei
- Department of Clinical Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
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Ikizler TA, Burrowes JD, Byham-Gray LD, Campbell KL, Carrero JJ, Chan W, Fouque D, Friedman AN, Ghaddar S, Goldstein-Fuchs DJ, Kaysen GA, Kopple JD, Teta D, Yee-Moon Wang A, Cuppari L. KDOQI Clinical Practice Guideline for Nutrition in CKD: 2020 Update. Am J Kidney Dis 2020; 76:S1-S107. [PMID: 32829751 DOI: 10.1053/j.ajkd.2020.05.006] [Citation(s) in RCA: 793] [Impact Index Per Article: 198.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/29/2020] [Indexed: 12/14/2022]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for nutrition in kidney diseases since 1999. Since the publication of the first KDOQI nutrition guideline, there has been a great accumulation of new evidence regarding the management of nutritional aspects of kidney disease and sophistication in the guidelines process. The 2020 update to the KDOQI Clinical Practice Guideline for Nutrition in CKD was developed as a joint effort with the Academy of Nutrition and Dietetics (Academy). It provides comprehensive up-to-date information on the understanding and care of patients with chronic kidney disease (CKD), especially in terms of their metabolic and nutritional milieu for the practicing clinician and allied health care workers. The guideline was expanded to include not only patients with end-stage kidney disease or advanced CKD, but also patients with stages 1-5 CKD who are not receiving dialysis and patients with a functional kidney transplant. The updated guideline statements focus on 6 primary areas: nutritional assessment, medical nutrition therapy (MNT), dietary protein and energy intake, nutritional supplementation, micronutrients, and electrolytes. The guidelines primarily cover dietary management rather than all possible nutritional interventions. The evidence data and guideline statements were evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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7
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Plastina JCR, Obara VY, Barbosa DS, Morimoto HK, Reiche EMV, Graciano A, Delfino VDA. Functional iron deficiency in patients on hemodialysis: prevalence, nutritional assessment, and biomarkers of oxidative stress and inflammation. ACTA ACUST UNITED AC 2020; 41:472-480. [PMID: 31441929 PMCID: PMC6979568 DOI: 10.1590/2175-8239-jbn-2018-0092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 05/13/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Anemic patients with chronic kidney disease (CKD) can be divided into anemic patients without or with functional iron deficiency (FID). The increase in the number of cases of hemosiderosis in patients on hemodialysis (HD) attributed to excessive intravenous iron replacement has called for the investigation of the factors involved in the genesis of FID. OBJECTIVES This study aimed to describe the prevalence of FID in patients with CKD on HD, characterize the included individuals in terms of clinical and workup parameters, and assess their nutritional, oxidative stress, and inflammation statuses. This cross-sectional study assembled a convenience sample of 183 patients with CKD on HD treated in Southern Brazil. Patients meeting the inclusion and exclusion criteria were divided into two groups, one with anemic subjects with FID and one with anemic patients without FID. Participants answered a questionnaire probing into socio-epidemiological factors, underwent anthropometric measurements, and were tested for markers of anemia, oxidative stress, inflammation, and nutrition. STATISTICAL ANALYSIS The date sets were treated on software package GraphPad InStat version 3.1. Variables were tested with the Kolmogorov-Smirnov, chi-square, Student's t, and Mann-Whitney tests. Statistical significance was attributed to differences with a p < 0.05. RESULTS Markers of inflammation were not statistically different between the two groups. Markers of anemia and nutrition were significantly lower in patients with FID. Patients with FID were prescribed higher doses of parenteral iron (p < 0,05). DISCUSSION FID was associated with lower nutritional marker levels, but not to increased levels of markers of inflammation or oxidative stress, as reported in the literature. Additional studies on the subject are needed.
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Affiliation(s)
| | - Vitor Y Obara
- Universidade Estadual de Londrina, Centro de Ciências da Saúde, Londrina, PR, Brasil
| | - Décio Sabbatini Barbosa
- Universidade Estadual de Londrina, Departamento de Patologia, Análises Clínicas e Toxicológicas, Londrina, PR, Brasil
| | - Helena Kaminami Morimoto
- Universidade Estadual de Londrina, Departamento de Patologia, Análises Clínicas e Toxicológicas, Londrina, PR, Brasil
| | - Edna Maria Vissoci Reiche
- Universidade Estadual de Londrina, Departamento de Patologia, Análises Clínicas e Toxicológicas, Londrina, PR, Brasil
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8
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Urquhart BL, House AA. Assessing Plasma Total Homocysteine in Patients with End-Stage Renal Disease. Perit Dial Int 2020. [DOI: 10.1177/089686080702700502] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Elevated plasma total homocysteine (tHcy) is a risk factor for cardiovascular disease; however, in light of several recent randomized trials, the issue of causality has been cast into doubt. Patients with end-stage renal disease are particularly interesting as they consistently have elevated tHcy and their leading causes of morbidity and mortality are related to cardiovascular disease. In the present article, we review the early evidence for the homocysteine theory of atherosclerosis, homocysteine metabolism, mechanisms of toxicity, and pertinent available clinical investigations. Where appropriate, the sparse evidence of homocysteine in peritoneal dialysis is reviewed. We conclude by addressing the difficulties associated with lowering plasma tHcy in patients with end-stage renal disease and suggest some novel methods for lowering tHcy in this resistant population. Finally, to address the issue of causality, we recommend that clinicians and scientists await the results of the FAVORIT trial before abandoning homocysteine as a modifiable risk factor for cardiovascular disease, as this study has recruited patients from a population with consistently elevated plasma tHcy who are known to respond to vitamin therapy.
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Affiliation(s)
- Bradley L. Urquhart
- Departments of Medicine The University of Western Ontario, London, Ontario, Canada
- Physiology/Pharmacology, The University of Western Ontario, London, Ontario, Canada
| | - Andrew A. House
- Departments of Medicine The University of Western Ontario, London, Ontario, Canada
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Yang H, Juang SY, Liao KF, Chen YH. Comparing the Effect of Folic Acid and Pentoxifylline on Delaying Dialysis Initiation in Patients with Advanced Chronic Kidney Disease. Nutrients 2019; 11:nu11092192. [PMID: 31547288 PMCID: PMC6769878 DOI: 10.3390/nu11092192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/04/2019] [Accepted: 09/07/2019] [Indexed: 11/17/2022] Open
Abstract
Background: We hypothesized that the nutrient loss and chronic inflammation status may stimulate progression in advanced chronic kidney disease. Therefore, we aimed to generate a study to state the influence of combined nutritional and anti-inflammatory interventions. Methods: The registry from the National Health Insurance Research Database in Taiwan was searched for 20–90 years individuals who had certified end-stage renal disease. From January 2005 through December 2010, the diagnosis code ICD-9 585 (chronic kidney disease, CKD) plus erythropoiesis-stimulating agent (ESA) use was defined as entering advanced chronic kidney disease. The ESA starting date was defined as the first index date, whereas the initiation day of maintenance dialysis was defined as the second index date. The duration between the index dates was analyzed in different medical treatments. Results: There were 10,954 patients analyzed. The combination therapy resulted in the longest duration (n = 2184, median 145 days, p < 0.001) before the dialysis initiation compared with folic acid (n = 5073, median 111 days), pentoxifylline (n = 1119, median 102 days, p = 0.654), and no drug group (control, n = 2578, median 89 days, p < 0.001). Lacking eGFR data and the retrospective nature are important limitations. Conclusions: In patients with advanced CKD on the ESA treatment, the combination of folic acid and pentoxifylline was associated with delayed initiation of hemodialysis.
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Affiliation(s)
- Hsun Yang
- Department of Nephrology, Department of Internal Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 427, Taiwan.
| | - Shiun-Yang Juang
- Department of Medical Research, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 427, Taiwan.
| | - Kuan-Fu Liao
- Division of Gastroenterology, Department of Internal Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 427, Taiwan.
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
- Graduate Institute of Integrated Medicine, China Medical University, Taichung 404, Taiwan.
| | - Yi-Hsin Chen
- Department of Nephrology, Department of Internal Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung 427, Taiwan.
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
- Institute of Clinical Medicine, National Yang-Ming University School of Medicine, Taipei 112, Taiwan.
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Capelli I, Cianciolo G, Gasperoni L, Zappulo F, Tondolo F, Cappuccilli M, La Manna G. Folic Acid and Vitamin B12 Administration in CKD, Why Not? Nutrients 2019; 11:nu11020383. [PMID: 30781775 PMCID: PMC6413093 DOI: 10.3390/nu11020383] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/09/2019] [Accepted: 02/11/2019] [Indexed: 12/13/2022] Open
Abstract
Patients affected by chronic kidney disease (CKD) or end-stage renal disease (ESRD) experience a huge cardiovascular risk and cardiovascular events represent the leading causes of death. Since traditional risk factors cannot fully explain such increased cardiovascular risk, interest in non-traditional risk factors, such as hyperhomocysteinemia and folic acid and vitamin B12 metabolism impairment, is growing. Although elevated homocysteine blood levels are often seen in patients with CKD and ESRD, whether hyperhomocysteinemia represents a reliable cardiovascular and mortality risk marker or a therapeutic target in this population is still unclear. In addition, folic acid and vitamin B12 could not only be mere cofactors in the homocysteine metabolism; they may have a direct action in determining tissue damage and cardiovascular risk. The purpose of this review was to highlight homocysteine, folic acid and vitamin B12 metabolism impairment in CKD and ESRD and to summarize available evidences on hyperhomocysteinemia, folic acid and vitamin B12 as cardiovascular risk markers, therapeutic target and risk factors for CKD progression.
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Affiliation(s)
- Irene Capelli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Giuseppe Cianciolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Lorenzo Gasperoni
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Fulvia Zappulo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Francesco Tondolo
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Maria Cappuccilli
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
| | - Gaetano La Manna
- Department of Experimental Diagnostic and Specialty Medicine (DIMES), Nephrology, Dialysis and Renal Transplant Unit, S. Orsola Hospital, University of Bologna, 40138 Bologna, Italy.
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Jenkins DJ, Spence JD, Giovannucci EL, Kim YI, Josse R, Vieth R, Blanco Mejia S, Viguiliouk E, Nishi S, Sahye-Pudaruth S, Paquette M, Patel D, Mitchell S, Kavanagh M, Tsirakis T, Bachiri L, Maran A, Umatheva N, McKay T, Trinidad G, Bernstein D, Chowdhury A, Correa-Betanzo J, Del Principe G, Hajizadeh A, Jayaraman R, Jenkins A, Jenkins W, Kalaichandran R, Kirupaharan G, Manisekaran P, Qutta T, Shahid R, Silver A, Villegas C, White J, Kendall CW, Pichika SC, Sievenpiper JL. Supplemental Vitamins and Minerals for CVD Prevention and Treatment. J Am Coll Cardiol 2018; 71:2570-2584. [DOI: 10.1016/j.jacc.2018.04.020] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/26/2018] [Accepted: 04/17/2018] [Indexed: 12/14/2022]
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Martí-Carvajal AJ, Solà I, Lathyris D, Dayer M. Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev 2017; 8:CD006612. [PMID: 28816346 PMCID: PMC6483699 DOI: 10.1002/14651858.cd006612.pub5] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cardiovascular disease, which includes coronary artery disease, stroke and peripheral vascular disease, is a leading cause of death worldwide. Homocysteine is an amino acid with biological functions in methionine metabolism. A postulated risk factor for cardiovascular disease is an elevated circulating total homocysteine level. The impact of homocysteine-lowering interventions, given to patients in the form of vitamins B6, B9 or B12 supplements, on cardiovascular events has been investigated. This is an update of a review previously published in 2009, 2013, and 2015. OBJECTIVES To determine whether homocysteine-lowering interventions, provided to patients with and without pre-existing cardiovascular disease are effective in preventing cardiovascular events, as well as reducing all-cause mortality, and to evaluate their safety. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (1946 to 1 June 2017), Embase (1980 to 2017 week 22) and LILACS (1986 to 1 June 2017). We also searched Web of Science (1970 to 1 June 2017). We handsearched the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search. SELECTION CRITERIA We included randomised controlled trials assessing the effects of homocysteine-lowering interventions for preventing cardiovascular events with a follow-up period of one year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease. DATA COLLECTION AND ANALYSIS We performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We calculated the number needed to treat for an additional beneficial outcome (NNTB). We measured statistical heterogeneity using the I2 statistic. We used a random-effects model. We conducted trial sequential analyses, Bayes factor, and fragility indices where appropriate. MAIN RESULTS In this third update, we identified three new randomised controlled trials, for a total of 15 randomised controlled trials involving 71,422 participants. Nine trials (60%) had low risk of bias, length of follow-up ranged from one to 7.3 years. Compared with placebo, there were no differences in effects of homocysteine-lowering interventions on myocardial infarction (homocysteine-lowering = 7.1% versus placebo = 6.0%; RR 1.02, 95% confidence interval (CI) 0.95 to 1.10, I2 = 0%, 12 trials; N = 46,699; Bayes factor 1.04, high-quality evidence), death from any cause (homocysteine-lowering = 11.7% versus placebo = 12.3%, RR 1.01, 95% CI 0.96 to 1.06, I2 = 0%, 11 trials, N = 44,817; Bayes factor = 1.05, high-quality evidence), or serious adverse events (homocysteine-lowering = 8.3% versus comparator = 8.5%, RR 1.07, 95% CI 1.00 to 1.14, I2 = 0%, eight trials, N = 35,788; high-quality evidence). Compared with placebo, homocysteine-lowering interventions were associated with reduced stroke outcome (homocysteine-lowering = 4.3% versus comparator = 5.1%, RR 0.90, 95% CI 0.82 to 0.99, I2 = 8%, 10 trials, N = 44,224; high-quality evidence). Compared with low doses, there were uncertain effects of high doses of homocysteine-lowering interventions on stroke (high = 10.8% versus low = 11.2%, RR 0.90, 95% CI 0.66 to 1.22, I2 = 72%, two trials, N = 3929; very low-quality evidence).We found no evidence of publication bias. AUTHORS' CONCLUSIONS In this third update of the Cochrane review, there were no differences in effects of homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination comparing with placebo on myocardial infarction, death from any cause or adverse events. In terms of stroke, this review found a small difference in effect favouring to homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination comparing with placebo.There were uncertain effects of enalapril plus folic acid compared with enalapril on stroke; approximately 143 (95% CI 85 to 428) people would need to be treated for 5.4 years to prevent 1 stroke, this evidence emerged from one mega-trial.Trial sequential analyses showed that additional trials are unlikely to increase the certainty about the findings of this issue regarding homocysteine-lowering interventions versus placebo. There is a need for additional trials comparing homocysteine-lowering interventions combined with antihypertensive medication versus antihypertensive medication, and homocysteine-lowering interventions at high doses versus homocysteine-lowering interventions at low doses. Potential trials should be large and co-operative.
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Zhao M, Wu G, Li Y, Wang X, Hou FF, Xu X, Qin X, Cai Y. Meta-analysis of folic acid efficacy trials in stroke prevention: Insight into effect modifiers. Neurology 2017; 88:1830-1838. [PMID: 28404799 DOI: 10.1212/wnl.0000000000003909] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 02/13/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the efficacy and effect modifiers of folic acid supplementation in the prevention of stroke in regions without folic acid fortification based on relevant, up-to-date published randomized trials. METHODS Relative risk (RR) was used to measure the effect of folic acid supplementation on risk of stroke using a fixed effects model. FINDINGS Overall, folic acid supplementation significantly reduced the stroke risk by 11% (22 trials, n = 82,723; RR 0.89, 95% confidence interval [CI] 0.84-0.96). The effect was greater in low folate regions (2 trials, n = 24,020; Asia, 0.78, 0.67-0.90) compared to high folate regions (7 trials, n = 14,655; America, 1.05, 0.90-1.23), and among patients without folic acid fortification (11 trials, n = 49,957; 0.85; 0.77-0.94) compared with those with folic acid fortification (7 trials, n = 14,655; 1.05, 0.90-1.23). In further stratified analyses among trials without folic acid fortification, a larger beneficial effect was found in those trials that used a low dosage of folic acid (≤0.8 mg: 0.78, 0.69-0.88) or low baseline vitamin B12 levels (<384 pg/mL: 0.78, 0.68-0.89). In the corresponding comparison groups, the effect sizes were attenuated and insignificant (p for interaction <0.05 for both). Although the interaction tests were not significant, there might be a higher benefit in trials with a low dosage of vitamin B12, a low prevalence of statin use, but a high prevalence of hypertension. CONCLUSIONS Folic acid supplementation could reduce the stroke risk in regions without folic acid fortification, particularly in trials using a relatively low dosage of folic acid and with low vitamin B12 levels.
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Affiliation(s)
- Min Zhao
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Guangliang Wu
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Youbao Li
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xiaobin Wang
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Fan Fan Hou
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xiping Xu
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xianhui Qin
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China.
| | - Yefeng Cai
- From the National Clinical Research Study Center for Kidney Disease (M.Z., Y.L., F.F.H., X.X., X.Q.), State Key Laboratory for Organ Failure Research, Renal Division, Nanfang Hospital, Southern Medical University; Second Clinical Medical College of Guangzhou University of Chinese Medicine (G.W.), Guangdong, China; Department of Population, Family, and Reproductive Health (X.W.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; and Department of Neurology (M.Z., Y.C.), Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China.
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Aftab RA, Khan AH, Syed Sulaiman SA, Khan TM, Adnan AS. Protocol of randomized control trial for effectiveness of angiotensin receptor blockers on blood pressure control among euvolemic hypertensive hemodialysis patients. Medicine (Baltimore) 2017; 96:e6198. [PMID: 28383400 PMCID: PMC5411184 DOI: 10.1097/md.0000000000006198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Volume overload and the renin-aldosterone-angiotensin system (RAAS) are 2 major factors contributing to hypertension (HTN) among hemodialysis (HD) patients. Although volume-dependent components of HTN can be corrected by appropriate volume removal, a proportion of HD patients experience elevated blood pressure (BP) despite achieving euvolemic and ideal dry weight. METHOD AND ANALYSIS A single center, prospective, randomized, parallel design, single-blind trial will be conducted in the Malaysian state of Kelantan among postdialysis euvolemic hypertensive patients that are on regular dialysis at least 3 times a week. The primary outcome of the trial will be to note the effectiveness of losartan (RAAS inhibitor) in reducing systolic BP < 140 mm Hg compared to standard non-RAAS-inhibitor antihypertensive therapy. The secondary outcome will be to look at all causes of mortality. A body composition monitor (BCM) will be used to assess postdialysis volume and dry weight. Postdialysis euvolemic patients that have systolic BP > 140 mm Hg will be randomized using Covariate Adaptive Randomization to standard or treatment arm. Participants in the treatment arm will be given 50 mg of losartan once daily except on dialysis days, whereas the standard arm patients will be prescribed non-RAAS antihypertensive agents. The study participants will be followed for a period of 12 months. A Wilcoxon statistical test will be performed to note the difference in BP from baseline up to 12 months using Statistical Package for the Social Sciences (SPSS) 20. ETHICAL AND TRIAL REGISTRATION The study protocols are approved from the Ethical and Research Committee of the Universiti Sains Malaysia (USM/JEPeM/15050173). The trial is registered under the Australia New Zealand Clinical Trial Registry (ACTRN12615001322527). The trial was registered on 2/12/2015 and the 1st patient was enrolled on 10/12/2015. The trial was formally initiated on 16/02/2016. CONCLUSION Management of HTN among HD patients requires understanding the primary cause of HTN and treating accordingly. The current trial is an attempt to reduce BP among postdialysis euvolemic but hypertensive patients.
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Affiliation(s)
- Raja Ahsan Aftab
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang
- CKD Resource Centre, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang
| | - Syed Azhar Syed Sulaiman
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang
| | - Tahir Mehmood Khan
- School of Pharmacy, Monash University, Jalan Lagoon Selatan, Bandar Sunway, Selangor, Malaysia
| | - Azreen Syazril Adnan
- CKD Resource Centre, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan
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Li Y, Huang T, Zheng Y, Muka T, Troup J, Hu FB. Folic Acid Supplementation and the Risk of Cardiovascular Diseases: A Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2016; 5:JAHA.116.003768. [PMID: 27528407 PMCID: PMC5015297 DOI: 10.1161/jaha.116.003768] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Results from observational and genetic epidemiological studies suggest that lower serum homocysteine levels are associated with lower incidence of cardiovascular disease (CVD). Numerous randomized controlled trials have investigated the efficacy of lowering homocysteine with folic acid supplementation for CVD risk, but conflicting results have been reported. METHODS AND RESULTS Three bibliographic databases (Medline, Embase, and the Cochrane Database of Systematic Reviews) were searched from database inception until December 1, 2015. Of the 1933 references reviewed for eligibility, 30 randomized controlled trials involving 82 334 participants were included in the final analysis. The pooled relative risks of folic acid supplementation compared with controls were 0.90 (95% CI 0.84-0.96; P=0.002) for stroke, 1.04 (95% CI 0.99-1.09; P=0.16) for coronary heart disease, and 0.96 (95% CI 0.92-0.99; P=0.02) for overall CVD. The intervention effects for both stroke and combined CVD were more pronounced among participants with lower plasma folate levels at baseline (both P<0.02 for interaction). In stratified analyses, a greater beneficial effect for overall CVD was seen in trials among participants without preexisting CVD (P=0.006 for interaction) or in trials with larger reduction in homocysteine levels (P=0.009 for interaction). CONCLUSIONS Our meta-analysis indicated a 10% lower risk of stroke and a 4% lower risk of overall CVD with folic acid supplementation. A greater benefit for CVD was observed among participants with lower plasma folate levels and without preexisting CVD and in studies with larger decreases in homocysteine levels. Folic acid supplementation had no significant effect on risk of coronary heart disease.
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Affiliation(s)
- Yanping Li
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Tianyi Huang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yan Zheng
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Tauland Muka
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Jenna Troup
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Frank B Hu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Nigwekar SU, Kang A, Zoungas S, Cass A, Gallagher MP, Kulshrestha S, Navaneethan SD, Perkovic V, Strippoli GFM, Jardine MJ. Interventions for lowering plasma homocysteine levels in dialysis patients. Cochrane Database Syst Rev 2016; 2016:CD004683. [PMID: 27243372 PMCID: PMC8520736 DOI: 10.1002/14651858.cd004683.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND People with end-stage kidney disease (ESKD) have high rates of cardiovascular events. Randomised controlled trials (RCTs) of homocysteine-lowering therapies have not shown reductions in cardiovascular event rates in the general population. However, people with kidney disease have higher levels of homocysteine and may have different mechanisms of cardiovascular disease. We performed a systematic review of the effect of homocysteine-lowering therapies in people with ESKD. OBJECTIVES To evaluate the benefits and harms of established homocysteine lowering therapy (folic acid, vitamin B6, vitamin B12) on all-cause mortality and cardiovascular event rates in patients with ESKD. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register to 25 January 2016 through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA Studies conducted in people with ESKD that reported at least 100 patient-years of follow-up and assessed the effect of therapies that are known to have homocysteine-lowering properties were included. DATA COLLECTION AND ANALYSIS Two authors independently extracted data using a standardised form. The primary outcome was cardiovascular mortality. Secondary outcomes included all-cause mortality, incident cardiovascular disease (fatal and nonfatal myocardial infarction and coronary revascularisation), cerebrovascular disease (stroke and cerebrovascular revascularisation), peripheral vascular disease (lower limb amputation), venous thromboembolic disease (deep vein thrombosis and pulmonary embolism), thrombosis of dialysis access, and adverse events. The effects of homocysteine-lowering therapies on outcomes were assessed with meta-analyses using random-effects models. Prespecified subgroup and sensitivity analyses were conducted. MAIN RESULTS We included six studies that reported data on 2452 participants with ESKD. Interventions investigated were folic acid with or without other vitamins (vitamin B6, vitamin B12). Participants' mean age was 48 to 65 years, and proportions of male participants ranged from 50% to 98%.Homocysteine-lowering therapy probably leads to little or no effect on cardiovascular mortality (4 studies, 1186 participants: RR 0.93, 95% CI 0.70 to 1.22). There was no evidence of heterogeneity among the included studies (I² = 0%). Homocysteine-lowering therapy had little or no effect on all-cause mortality or any other of this review's secondary outcomes. All prespecified subgroup and sensitivity analyses demonstrated little or no difference. Reported adverse events were mild and there was no increase in the incidence of adverse events from homocysteine-lowering therapies (3 studies, 1248 participants: RR 1.12, 95% CI 0.51 to 2.47; I(2) = 0%). Overall, studies were assessed as being at low risk of bias and there was no evidence of publication bias. AUTHORS' CONCLUSIONS Homocysteine-lowering therapies were not found to reduce mortality (cardiovascular and all-cause) or cardiovascular events among people with ESKD.
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Affiliation(s)
- Sagar U Nigwekar
- Harvard Medical SchoolDivision of Nephrology, Massachusetts General Hospital, Scholars in Clinical Sciences ProgramBostonMAUSA
| | - Amy Kang
- The University of SydneySydney Medical SchoolSydneyNSWAustralia
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Sophia Zoungas
- Monash UniversityDiabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
| | - Alan Cass
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionCamperdownNSWAustralia
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Martin P Gallagher
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Satyarth Kulshrestha
- University of Iowa Carver College of MedicineDepartment of Nephrology200 Hawkins Drive‐T307GHIowa CityIAUSA52242
| | | | - Vlado Perkovic
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Giovanni FM Strippoli
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Meg J Jardine
- The George Institute for Global Health, The University of SydneyRenal and Metabolic DivisionCamperdownNSWAustralia
- Concord Repatriation General HospitalDepartment of Renal MedicineHospital RoadConcordNSWAustralia2139
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Kang A, Nigwekar SU, Perkovic V, Kulshrestha S, Zoungas S, Navaneethan SD, Cass A, Gallagher MP, Ninomiya T, Strippoli GFM, Jardine MJ. Interventions for lowering plasma homocysteine levels in kidney transplant recipients. Cochrane Database Syst Rev 2015; 2015:CD007910. [PMID: 25938479 PMCID: PMC10788770 DOI: 10.1002/14651858.cd007910.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Elevated homocysteine levels have been shown to be an independent risk factor for cardiovascular disease. However studies of homocysteine lowering in general and end-stage kidney disease (ESKD) populations have not demonstrated a reduction in cardiovascular event rates. Kidney transplant recipients have high homocysteine levels, high cardiovascular event rates and, unlike the ESKD population, may achieve normalisation of homocysteine levels with homocysteine lowering therapies. Thus may benefit from homocysteine lowering therapy. OBJECTIVES To evaluate the effects of established homocysteine lowering therapy on cardiovascular mortality in patients with functioning kidney transplants. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 16 March 2015 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials of any therapy that has been shown to significantly lower homocysteine levels conducted in people with functioning kidney transplants. Studies were to be included if they compared homocysteine lowering therapy with placebo or usual care, or compare higher versus lower doses of homocysteine lowering therapy. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Results were to be expressed as the risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Data was to be pooled using the random effects model. MAIN RESULTS The literature search yielded 359 reports of which only one study was identified that met our inclusion criteria and reported relevant clinical endpoints. This study randomised 4110 adult participants with a functioning kidney transplant and elevated homocysteine levels to folic acid plus high dose B multivitamins or low dose multivitamins who were followed for a mean 4.0 years. Despite effectively lowering homocysteine levels) in homocysteine levels at follow-up (MD -4.40 μmol/L, 95% CI -5.98 to -2.82) there was no evidence the intervention impacted on any of the outcomes reported including cardiovascular mortality (RR 0.91, 95% CI 0.69 to 1.20), all-cause mortality (RR 1.04, 95% CI 0.88 to 1.22), myocardial infarction (RR 1.02, 95% CI 0.77 to 1.35), stroke (RR 1.08, 95% CI 0.69 to 1.71), commencement of renal replacement therapy (RR 1.12, 95% CI 0.91 to 1.37) or all reported adverse events (RR 1.02, 95% CI 0.87 to 1.20). There was no evidence the intervention impacted on the primary endpoint of the study, a cardiovascular event composite (RR 0.99, 95% CI 0.85 to 1.15). The study was of high quality. AUTHORS' CONCLUSIONS There is no current evidence to support the use of homocysteine lowering therapy for cardiovascular disease prevention in kidney transplant recipients.
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Affiliation(s)
- Amy Kang
- The University of SydneySydney Medical SchoolCamperdownNSWAustralia
| | - Sagar U Nigwekar
- Harvard Medical SchoolBrigham and Women's Hospital, Massachusetts General Hospital, Scholars in Clinical Sciences ProgramBostonMAUSA
| | - Vlado Perkovic
- The George Institute for Global HealthCamperdownNSWAustralia
| | - Satyarth Kulshrestha
- University of Iowa Carver College of MedicineNephrology200 Hawkins Drive‐T307GHIowa CityIAUSA52242
| | - Sophia Zoungas
- Monash UniversityDiabetes and Vascular Research Program, Monash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
| | - Sankar D Navaneethan
- Glickman Urological and Kidney Institute, Cleveland ClinicDepartment of Nephrology and HypertensionClevelandOHUSA44195
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Martin P Gallagher
- The George Institute for Global HealthRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Toshiharu Ninomiya
- The George Institute for Global HealthRenal and Metabolic DivisionCamperdownNSWAustralia
| | - Giovanni FM Strippoli
- The Children’s Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchWestmeadAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum Medical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
| | - Meg J Jardine
- The University of SydneyThe George Institute for Global HealthPO Box M201Missenden RdCamperdownNSWAustralia2050
- Concord Repatriation General HospitalDepartment of Renal MedicineHospital RoadConcordNSWAustralia2139
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Martí-Carvajal AJ, Solà I, Lathyris D. Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev 2015; 1:CD006612. [PMID: 25590290 DOI: 10.1002/14651858.cd006612.pub4] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiovascular disease, which includes coronary artery disease, stroke and congestive heart failure, is a leading cause of death worldwide. Homocysteine is an amino acid with biological functions in methionine metabolism. A postulated risk factor is an elevated circulating total homocysteine level, which is associated with cardiovascular events. The impact of homocysteine-lowering interventions, given to patients in the form of vitamins B6, B9 or B12 supplements, on cardiovascular events. This is an update of a review previously published in 2009 and 2013. OBJECTIVES To determine whether homocysteine-lowering interventions, provided in patients with and without pre-existing cardiovascular disease are effective in preventing cardiovascular events, as well as all-cause mortality and evaluate their safety. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1), MEDLINE (1950 to January week 5 2014), EMBASE (1980 to 2014 week 6) and LILACS (1986 to February 2014). We also searched Web of Science (1970 to 7 February 2014). We handsearched the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search. SELECTION CRITERIA We included randomised controlled trials assessing the effects of homocysteine-lowering interventions for preventing cardiovascular events with a follow-up period of one year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease. DATA COLLECTION AND ANALYSIS We performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model. MAIN RESULTS In this second updated Cochrane Review, we identified no new randomised controlled trials. Therefore, this new version includes 12 randomised controlled trials involving 47,429 participants. In general terms, 75% (9/12) trials had a low risk of bias. Homocysteine-lowering interventions compared with placebo did not significantly affect non-fatal or fatal myocardial infarction (1743/23,590 (7.38%) versus 1247/20,190 (6.17%); RR 1.02, 95% confidence interval (CI) 0.95 to 1.10, I(2) = 0%, high quality evidence), stroke (968/22,348 (4.33%) versus 974/18,957 (5.13%); RR 0.91, 95% CI 0.82 to 1.0, I(2) = 11%, high quality evidence) or death from any cause (2784/22,648 (12.29%) versus 2502/19,250 (10.64%); RR 1.01, 95% CI 0.96 to 1.07, I(2) = 6%, high quality evidence). Homocysteine-lowering interventions compared with placebo did not significantly affect serious adverse events (cancer) (1558/18,130 (8.59%) versus 1334/14,739 (9.05%); RR 1.06, 95% CI 0.98 to 1.13; I(2) = 0%, high quality evidence). AUTHORS' CONCLUSIONS This second update of this Cochrane Review found no evidence to suggest that homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination should be used for preventing cardiovascular events. Furthermore, there is no evidence to suggest that homocysteine-lowering interventions are associated with an increased risk of cancer.
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Raghban A, Kirsop J, Tang WHW. Prevention of Heart Failure in Patients with Chronic Kidney Disease. CURRENT CARDIOVASCULAR RISK REPORTS 2015; 9:428. [PMID: 38993263 PMCID: PMC11238633 DOI: 10.1007/s12170-014-0428-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Patients with chronic kidney disease (CKD) have heightened risk of developing heart failure (HF), yet few clinical studies have directly investigated the pathophysiologic underpinnings or therapeutic strategies to prevent HF. A wide range of clinically available cardiac and renal biomarkers can identify at-risk individuals who would benefit from dietary and lifestyle modifications (exercise prescription, smoking cessation), as well as risk factor modification (blood pressure, glucose, and lipid control). Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have the most consistent data for risk reduction, while other standard HF drugs such as beta-blockers and mineralocorticoid receptor antagonists have promising findings but no large-scale clinical trial evidence for their routine use to prevent the development and progression of HF in this vulnerable population.
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Affiliation(s)
- Amr Raghban
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Jennifer Kirsop
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
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Debreceni B, Debreceni L. The role of homocysteine-lowering B-vitamins in the primary prevention of cardiovascular disease. Cardiovasc Ther 2014; 32:130-8. [PMID: 24571382 DOI: 10.1111/1755-5922.12064] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality in the Western world. The effort of research should aim at the primary prevention of CVD. Alongside statin therapy, which is maintained to be an effective method of CVD prevention, there are alternative methods such as vitamin B substitution therapy with folic acid (FA), and vitamins B12 and B6 . B-vitamins may inhibit atherogenesis by decreasing the plasma level of homocysteine (Hcy)-a suspected etiological factor for atherosclerosis-and by other mechanisms, primarily through their antioxidant properties. Although Hcy-lowering vitamin trials have failed to demonstrate beneficial effects of B-vitamins in the prevention of CVD, a meta-analysis and stratification of a number of large vitamin trials have suggested their effectiveness in cardiovascular prevention (CVP) in some aspects. Furthermore, interpretation of the results from these large vitamin trials has been troubled by statin/aspirin therapy, which was applied along with the vitamin substitution, and FA fortification, both of which obscured the separate effects of vitamins in CVP. Recent research results have accentuated a new approach to vitamin therapy for CVP. Studies undertaken with the aim of primary prevention have shown that vitamin B substitution may be effective in the primary prevention of CVD and may also be an option in the secondary prevention of disease if statin therapy is accompanied by serious adverse effects. Further investigations are needed to determine the validity of vitamin substitution therapy before its introduction in the protocol of CVD prevention.
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Affiliation(s)
- Balazs Debreceni
- Department of Biochemistry and Medical Chemistry, Medical School, University of Pecs, Pecs, Hungary
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The effect of folate fortification on folic acid-based homocysteine-lowering intervention and stroke risk: a meta-analysis. Public Health Nutr 2014; 18:1514-21. [DOI: 10.1017/s1368980014002134] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjectiveFolate and vitamin B12 are two vital regulators in the metabolic process of homocysteine, which is a risk factor of atherothrombotic events. Low folate intake or low plasma folate concentration is associated with increased stroke risk. Previous randomized controlled trials presented discordant findings in the effect of folic acid supplementation-based homocysteine lowering on stroke risk. The aim of the present review was to perform a meta-analysis of relevant randomized controlled trials to check the how different folate fortification status might affect the effects of folic acid supplementation in lowering homocysteine and reducing stroke risk.DesignRelevant randomized controlled trials were identified through formal literature search. Homocysteine reduction was compared in subgroups stratified by folate fortification status. Relative risks with 95 % confidence intervals were used as a measure to assess the association between folic acid supplementation and stroke risk.SettingThe meta-analysis included fourteen randomized controlled trials,SubjectsA total of 39 420 patients.ResultsHomocysteine reductions were 26·99 (sd 1·91) %, 18·38 (sd 3·82) % and 21·30 (sd 1·98) %, respectively, in the subgroups without folate fortification, with folate fortification and with partial folate fortification. Significant difference was observed between the subgroups with folate fortification and without folate fortification (P=0·05). The relative risk of stroke was 0·88 (95 % CI 0·77, 1·00, P=0·05) in the subgroup without folate fortification, 0·94 (95 % CI 0·58, 1·54, P=0·82) in the subgroup with folate fortification and 0·91 (95 % CI 0·82, 1·01, P=0·09) in the subgroup with partial folate fortification.ConclusionsFolic acid supplementation might have a modest benefit on stroke prevention in regions without folate fortification.
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Wang Y, Chen S, Yao T, Li D, Wang Y, Li Y, Wu S, Cai J. Homocysteine as a risk factor for hypertension: a 2-year follow-up study. PLoS One 2014; 9:e108223. [PMID: 25310282 PMCID: PMC4195588 DOI: 10.1371/journal.pone.0108223] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 08/27/2014] [Indexed: 11/24/2022] Open
Abstract
Homocysteine (Hcy) is regarded as a risk factor for hypertension, but research on the causal relationship between Hcy and hypertension is limited. In the present study, we prospectively tracked the blood pressure progression of a normotensive population with different Hcy levels over a 2-year period. The incidence of hypertension with increasing Hcy quartiles produced an approximately U-shaped curve, with significance in males. Compared with the third quartile, the risk of hypertension in the first and second quartiles was increased by 1.55 (95% confidence interval [CI] 1.154–2.081) fold and 1.501 (95% CI 1.119–2.013) fold, respectively, with the increase being more significant in males. In conclusion, Hcy is related to hypertension incidence with the results approximating an U-shaped curve. Low Hcy levels might also increase the risk of hypertension.
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Affiliation(s)
- Yixuan Wang
- Department of Cardiology, Beijing Chao-Yang Hospital, Capital Medical University, Chaoyang District, Beijing, China
| | - Shuohua Chen
- Health Department of Kailuan Group, Tangshan, China
| | - Tao Yao
- Linxi Hospital, Affiliated Kailuan General Hospital, Hebei United University, Tangshan, China
| | - DongQing Li
- Department of Cardiology, The Kailuan General Hospital, Hebei United University, Tangshan, China
| | - YanXiu Wang
- Department of Cardiology, The Kailuan General Hospital, Hebei United University, Tangshan, China
| | - YuQing Li
- Department of Rheumatology and Immunology, The Kailuan General Hospital, Hebei United University, Tangshan, China
| | - ShouLing Wu
- Department of Cardiology, The Kailuan General Hospital, Hebei United University, Tangshan, China
- * E-mail: (SW); (JC)
| | - Jun Cai
- Department of Cardiology, Beijing Chao-Yang Hospital, Capital Medical University, Chaoyang District, Beijing, China
- * E-mail: (SW); (JC)
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Zhang C, Wang ZY, Qin YY, Yu FF, Zhou YH. Association between B vitamins supplementation and risk of cardiovascular outcomes: a cumulative meta-analysis of randomized controlled trials. PLoS One 2014; 9:e107060. [PMID: 25238614 PMCID: PMC4169527 DOI: 10.1371/journal.pone.0107060] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 08/06/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Observational studies suggest that B vitamin supplementation reduces cardiovascular risk in adults, but this association remains controversial. This study aimed to summarize the evidence from randomized controlled trials (RCTs) investigating B vitamin supplementation for the primary or secondary prevention of major adverse cardiovascular outcomes and to perform a cumulative meta-analysis to determine the evidence base. METHODOLOGY AND PRINCIPAL FINDINGS In April 2013, we searched PubMed, Embase, and the Cochrane Library to identify relevant RCTs. We included RCTs investigating the effect of B vitamin supplementation on cardiovascular outcome. Relative risk (RR) was used to measure the effect using a random-effect model. Statistical heterogeneity scores were assessed using the Q statistic. We included data on 57,952 individuals from 24 RCTs: 12 primary prevention trials and 12 secondary prevention trials. In 23 of these trials, 10,917 major adverse cardiovascular events (MACE) occurred; in 20 trials, 7,203 deaths occurred; in 15 trials, 3,422 cardiac deaths occurred; in 19 trials, 3,623 myocardial infarctions (MI) occurred; and in 18 trials, 2,465 strokes occurred. B vitamin supplementation had little or no effect on the incidence of MACE (RR, 0.98; 95% confidence interval [CI]: 0.93-1.03; P = 0.37), total mortality (RR, 1.01; 95% CI: 0.97-1.05; P = 0.77), cardiac death (RR, 0.96; 95% CI: 0.90-1.02; P = 0.21), MI (RR, 0.99; 95% CI: 0.93-1.06; P = 0.82), or stroke (RR, 0.94; 95% CI: 0.85-1.03; P = 0.18). CONCLUSION/SIGNIFICANCE B vitamin supplementation, when used for primary or secondary prevention, is not associated with a reduction in MACE, total mortality, cardiac death, MI, or stroke.
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Affiliation(s)
- Chi Zhang
- Department of Neurosurgery, Shanghai Seventh People's Hospital, Shanghai, China
| | - Zhi-Yong Wang
- Department of Information, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ying-Yi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Fei-Fei Yu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yu-Hao Zhou
- Department of Rehabilitation Institute, Shanghai Seventh People's Hospital, Shanghai, China
- * E-mail:
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Qin X, Fan F, Cui Y, Chen F, Chen Y, Cheng X, Li Y, Wang B, Xu X, Xu X, Huo Y, Wang X. Folic acid supplementation with and without vitamin B6 and revascularization risk: a meta-analysis of randomized controlled trials. Clin Nutr 2014; 33:603-12. [PMID: 24461473 DOI: 10.1016/j.clnu.2014.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/22/2013] [Accepted: 01/05/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND & AIMS There is a growing amount of data and a continuing controversy over the effect of folic acid supplementation with and without vitamin B6 on revascularization risk. METHODS We conducted a meta-analysis based on up-to-date published relevant randomized trials to further examine this issue. Relative risk (RR) was used to measure the effect of folic acid supplementation on risk of revascularization using a random-effects model. Total revascularization was defined as any arterial revascularization. Restenosis was defined as stenosis of more than 50 percent of the luminal diameter. RESULTS Overall, folic acid supplementation had no significant effect on coronary revascularization (9 trials, n = 27,418, RR = 0.99; 95%CI:0.88-1.11, P = 0.88), coronary artery bypass grafting (CABG) (5 trials, n = 10,703, 0.90; 0.79-1.03, P = 0.11), percutaneous coronary intervention (PCI) (5 trials, n = 10,703, 1.05; 0.89-1.23, P = 0.59), coronary restenosis (3 trials, n = 926, 1.05; 0.89-1.23, P = 0.59) or total revascularization (7 trials, n = 29,314, 1.06; 95%CI: 0.99-1.13, P = 0.10). However, a greater beneficial effect was observed for coronary revascularization among those trials with a moderate dose of vitamin B6 (5-10 mg/d; RR: 0.47; 95%CI: 0.28-0.80, P = 0.005), but not in trials without vitamin B6 or with a high dose of vitamin B6. And a non-significant greater total revascularization risk was observed in trials with a higher folic acid dose (>2 mg/d, RR = 1.11; 95%CI: 0.98-1.25, P = 0.09; ≥5 mg/d, RR = 1.98; 95%CI: 0.93-4.20, P = 0.08). CONCLUSIONS Our analyses indicate that folic acid supplementation has no significant effect on coronary revascularization, CABG, PCI, coronary restenosis or total revascularization. However, a combination of folic acid and moderate vitamin B6 may be beneficial in reducing coronary revascularization risk.
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Affiliation(s)
- Xianhui Qin
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Institute of Biomedicine, Anhui Medical University, Hefei, China
| | - Fangfang Fan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Fang Chen
- Department of Cardiology, Capital Medical University Affiliated with Beijing Anzhen Hospital, Beijing, China
| | - Yundai Chen
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China
| | - Xiaoshu Cheng
- Department of Cardiology, Second Affiliated Hospital, Nanchang University, Nanchang, China
| | - Yuming Li
- Institute of Cardiovascular Disease and Heart Center, Pinjing Hospital Logistics University of the Chinese People's Armed Police Forces, Tianjin, China
| | - Binyan Wang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xin Xu
- Guangdong Institute of Nephrology, Southern Medical University, Guangzhou, China
| | - Xiping Xu
- Guangdong Institute of Nephrology, Southern Medical University, Guangzhou, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China.
| | - Xiaobin Wang
- Center on the Early Life Origins of Disease, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
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Martí-Carvajal AJ, Solà I, Lathyris D, Karakitsiou DE, Simancas-Racines D. Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev 2013:CD006612. [PMID: 23440809 DOI: 10.1002/14651858.cd006612.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cardiovascular disease (including coronary artery disease, stroke and congestive heart failure), is a leading cause of death worldwide. Homocysteine is an amino acid with biological functions in methionine metabolism. A postulated risk factor is elevated circulating total homocysteine levels, which are associated with cardiovascular events. This is an update of a review previously published in 2009. OBJECTIVES To assess the clinical effectiveness of homocysteine-lowering interventions in people with or without pre-existing cardiovascular disease. SEARCH METHODS We searched The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2012, Issue 2), MEDLINE (1950 to Feb week 2 2012), EMBASE (1980 to 2012 week 07), and LILACS (1986 to February 2012). We also searched ISI Web of Science (1970 to February 2012). We handsearched the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search. SELECTION CRITERIA We included randomised controlled trials assessing the effects of homocysteine-lowering interventions for preventing cardiovascular events with a follow-up period of one year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease. DATA COLLECTION AND ANALYSIS We performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using I(2). We used a random-effects model. MAIN RESULTS In this updated systematic review, we identified four new randomised trials, resulting in a total of 12 randomised controlled trials involving 47,429 participants. In general terms, the trials had a low risk of bias. Homocysteine-lowering interventions compared with placebo did not significantly affect non-fatal or fatal myocardial infarction (pooled RR 1.02, 95% CI 0.95 to 1.10, I(2) = 0%), stroke (pooled RR 0.91, 95% CI 0.82 to 1.0, I(2) = 11%) or death by any cause (pooled RR 1.01 (95% CI 0.96 to 1.07, I(2): 6%)). Homocysteine-lowering interventions compared with placebo did not significantly affect serious adverse events (cancer) (1 RR 1.06, 95% CI 0.98 to 1.13; I(2) = 0%). AUTHORS' CONCLUSIONS This updated Cochrane review found no evidence to suggest that homocysteine-lowering interventions in the form of supplements of vitamins B6, B9 or B12 given alone or in combination should be used for preventing cardiovascular events. Furthermore, there is no evidence suggesting that homocysteine-lowering interventions are associated with an increased risk of cancer.
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Affiliation(s)
- Arturo J Martí-Carvajal
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad Tecnológica Equinoccial, Quito, Ecuador.
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Qin X, Huo Y, Xie D, Hou F, Xu X, Wang X. Homocysteine-lowering therapy with folic acid is effective in cardiovascular disease prevention in patients with kidney disease: a meta-analysis of randomized controlled trials. Clin Nutr 2012; 32:722-7. [PMID: 23313356 DOI: 10.1016/j.clnu.2012.12.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 12/05/2012] [Accepted: 12/06/2012] [Indexed: 01/10/2023]
Abstract
BACKGROUND & AIMS The efficacy of homocysteine-lowering therapy with folic acid to lower homocysteine levels in an effort to reduce cardiovascular disease (CVD) risk in patients with kidney disease remains inconclusive. We conducted a meta-analysis of relevant randomized trials to further examine this issue. METHODS This meta-analysis included 8234 patients with kidney disease from nine qualified randomized trials using folic acid therapy, and with CVD reported as one of the endpoints. Relative risk (RR) was used to measure the effect of folic acid supplementation on risk of CVD using a random effects model. RESULTS When pooling the nine randomized trials, folic acid therapy reduced the risk of CVD by 10%(RR = 0.90; 95% CI:0.81-1.00, P = 0.046). A greater beneficial effect was observed among those trials without a history of grain fortification with folic acid (0.82; 0.70-0.96, P = 0.01), with lower percent baseline diabetes (<30% (median), 0.80; 0.65-0.99, P = 0.04), and in patients with end-stage renal disease (ESRD) or advanced chronic kidney disease (ACKD) (0.85; 0.77-0.94, P = 0.002). Furthermore, a meta-regression analysis suggested a positive dose-response relationship between percent baseline diabetes and log-RR for CVD risk associated with folic acid supplementation (P = 0.007). Most importantly, even the inclusion of three subgroup results did not substantially affect the results (n = 11032, RR: 0.93; 95% CI:0.87-0.99, P = 0.03). CONCLUSIONS Our meta-analysis indicates that folic acid supplementation may be effective for CVD prevention in patients with kidney disease, particularly in trials among patients without a history of grain fortification with folic acid, with lower percent baseline diabetes, and in patients with ESRD or ACKD.
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Affiliation(s)
- Xianhui Qin
- Institute of Biomedicine, Anhui Medical University, Hefei, China
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Jun M, Lv J, Perkovic V, Jardine MJ. Managing cardiovascular risk in people with chronic kidney disease: a review of the evidence from randomized controlled trials. Ther Adv Chronic Dis 2012; 2:265-78. [PMID: 23251754 DOI: 10.1177/2040622311401775] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cardiovascular disease is the leading cause of death and morbidity in people with chronic kidney disease (CKD) making measures to modify cardiovascular risk a clinical priority. The relationship between risk factors and cardiovascular outcomes is often substantially different in people with CKD compared with the general population, leading to uncertainty around pathophysiological mechanisms and the validity of generalizations from the general population. Furthermore, published reports of subgroup analyses from clinical trials have suggested that a range of interventions may have different effects in people with kidney disease compared with those with normal kidney function. There is a relative scarcity of randomized controlled trials (RCTs) conducted in CKD populations, and most such trials are small and underpowered. As a result, evidence to support cardiovascular risk modification measures for people with CKD is largely derived from small trials and post hoc analyses of RCTs conducted in the general population. In this review, we examine the available RCT evidence on interventions aimed at preventing cardiovascular events in people with kidney disease to identify beneficial treatments as well as current gaps in knowledge that should be a priority for future research.
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Affiliation(s)
- Min Jun
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
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28
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Yang HT, Lee M, Hong KS, Ovbiagele B, Saver JL. Efficacy of folic acid supplementation in cardiovascular disease prevention: an updated meta-analysis of randomized controlled trials. Eur J Intern Med 2012; 23:745-54. [PMID: 22884409 DOI: 10.1016/j.ejim.2012.07.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/28/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND In observational studies, lower serum homocysteine levels are associated with a lower incidence of cardiovascular disease (CVD). However, individual randomized controlled trials (RCTs) have yielded mixed findings regarding the efficacy of therapeutic homocysteine in lowering cardiovascular risk. Our aim was to perform an updated meta-analysis of relevant RCTs to assess the efficacy of folic acid supplementation in the prevention of CVD, coronary heart disease (CHD), and stroke. METHODS We performed systematic search to identify RCTs reported at least one of the CVD, CHD, or stroke as outcomes. Relative risk (RR) with 95% confidence interval was used as a measure of the association between folic acid supplementation and risk of CVD, CHD, stroke, and all-cause mortality. The analysis was further stratified by factors that could affect the treatment effects. RESULTS The systematic search identified 26 RCTs enrolling 58,804 participants. Pooling the RRs showed that folic acid supplementation was not associated with any significant change in the risk of CVD (RR 0.98, 0.95 to 1.02; p=0.36), CHD (RR 1.03, 0.98 to 1.08; p=0.23), and all-cause mortality (RR 1.00, 0.96 to 1.04; p=0.92), but was linked to a decreasing trend in stroke risk (RR 0.93, 0.86 to 1.00; p=0.05). In stratified analyses, the only heterogeneity was found for stroke risk reduction among groups with (RR 1.07, 0.92 to 1.25) vs. without (RR 0.88, 0.81 to 0.96) mandatory grain fortification (P for heterogeneity=0.03). CONCLUSIONS This meta-analysis suggests that there might be a potentially modest benefit of folic acid supplementation in stroke prevention.
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Affiliation(s)
- Hsin-Ta Yang
- Department of Neurology, Chang Gung Memorial Hospital at Chiayi, Chang Gung University College of Medicine, Taiwan
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Role of homocysteine in end-stage renal disease. Clin Biochem 2012; 45:1286-94. [PMID: 22683753 DOI: 10.1016/j.clinbiochem.2012.05.031] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 04/26/2012] [Accepted: 05/28/2012] [Indexed: 11/22/2022]
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30
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Medical options to fight mortality in end-stage renal disease: a review of the literature. Nephrol Dial Transplant 2012; 27:4298-307. [DOI: 10.1093/ndt/gfs400] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Jardine MJ, Kang A, Zoungas S, Navaneethan SD, Ninomiya T, Nigwekar SU, Gallagher MP, Cass A, Strippoli G, Perkovic V. The effect of folic acid based homocysteine lowering on cardiovascular events in people with kidney disease: systematic review and meta-analysis. BMJ 2012; 344:e3533. [PMID: 22695899 PMCID: PMC3374481 DOI: 10.1136/bmj.e3533] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2012] [Indexed: 12/13/2022]
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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Affiliation(s)
- Meg J Jardine
- George Institute for Global Health, PO Box M201, Camperdown, NSW 2050, Australia.
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Huo Y, Qin X, Wang J, Sun N, Zeng Q, Xu X, Liu L, Xu X, Wang X. Efficacy of folic acid supplementation in stroke prevention: new insight from a meta-analysis. Int J Clin Pract 2012; 66:544-51. [PMID: 22607506 DOI: 10.1111/j.1742-1241.2012.02929.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIMS There are growing data and a continuing controversy over the efficacy of folic acid supplementation in stroke prevention. We conducted a meta-analysis based on relevant, up-to-date published randomised trials to further examine this issue. METHODS Relative risk (RR) was used to measure the effect of folic acid supplementation on risk of stroke with a fixed-effects model. RESULTS Overall, folic acid supplementation reduced the risk of stroke by 8% (n = 55,764; RR: 0.92; 95% CI: 0.86-1.00, p = 0.038). In the 10 trials with no or partial folic acid fortification (n = 43,426), the risk of stroke was reduced by 11% (0.89; 0.82-0.97, p = 0.010). Within these trials, a greater beneficial effect was observed among trials with a lower percent use of statins [≤ 80% (median); 0.77; 0.64-0.92, p = 0.005], and a meta-regression analysis also suggested a positive dose-response relationship between percent use of statins and log-RR for stroke associated with folic acid supplementation (p = 0.013). A daily dose of 0.4-0.8mg folic acid appeared to be adequate for stroke prevention in comparison with larger doses. In the remaining five trials conducted in populations with folic acid fortification (n = 12,338), folic acid supplementation had no effect on stroke risk (1.03; 0.88-1.21, 0.69). CONCLUSIONS Our analysis indicated that folic acid supplementation is effective in stroke prevention in populations with no or partial folic acid fortification. In addition, a greater beneficial effect was observed among trials with a lower percent use of statins. Our findings underscore the importance of identifying target populations that can particularly benefit from folic acid therapy.
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Affiliation(s)
- Y Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China.
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Sunder-Plassmann G, Födinger M, Säemann MD. Cardiovascular Disease Mortality in Kidney Transplant Recipients: No Light at the End of the Tunnel? Am J Kidney Dis 2012; 59:754-7. [DOI: 10.1053/j.ajkd.2011.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 11/23/2011] [Indexed: 11/11/2022]
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Homocysteine-lowering therapy does not lead to reduction in cardiovascular outcomes in chronic kidney disease patients: a meta-analysis of randomised, controlled trials. Br J Nutr 2012; 108:400-7. [PMID: 22244447 DOI: 10.1017/s0007114511007033] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The efficacy of homocysteine (Hcy)-lowering therapy in reducing the risk of CVD among patients with chronic kidney disease (CKD) remains controversial. We performed a meta-analysis to determine whether pooling the data from the few small randomised, controlled trials that address this topic would improve the statistical power of the analysis and resolve some of the inconsistencies in the results. Randomised, controlled clinical trials (RCT) were identified from MEDLINE, EMBASE, www.clinicaltrials.gov, the Cochrane Controlled Clinical Trials Register Database and Nephrology Filters. Independent extraction of articles was performed using predefined data fields. The primary outcome was relative risk (RR) of CVD, CHD, stroke and all-cause mortality for the pooled trials. A stratified analysis was planned, assessing the RR for cardiovascular events between the patients on and not on dialysis. Overall, ten studies met the inclusion criteria. The estimated RR were not significantly different for any outcomes, including CHD (RR 1·00, 95 % CI 0·75, 1·31, P = 0·97), CVD (RR 0·94, 95 % CI 0·84, 1·05, P = 0·30), stroke (RR 0·83, 95 % CI 0·57, 1·19, P = 0·31) and all-cause mortality (RR 1·00, 95 % CI 0·92, 1·09, P = 0·98). In the stratified analysis, the estimated RR were not significantly different for cardiovascular events regardless of dialysis or in combination with vitamin B therapy or the degree of reduction in Hcy levels. Our meta-analysis of RCT supports the conclusion that Hcy-lowering therapy was not associated with a significant decrease in the risk for CVD events, stroke and all-cause mortality among patients with CKD.
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Qin X, Xu M, Zhang Y, Li J, Xu X, Wang X, Xu X, Huo Y. Effect of folic acid supplementation on the progression of carotid intima-media thickness: a meta-analysis of randomized controlled trials. Atherosclerosis 2011; 222:307-13. [PMID: 22209480 DOI: 10.1016/j.atherosclerosis.2011.12.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 12/02/2011] [Accepted: 12/05/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We conducted a meta-analysis of relevant randomized trials to assess whether folic acid supplementation reduces the progression of atherosclerosis as measured by carotid intima-media thickness (CIMT). METHODS This analysis included 2052 subjects from ten folic acid randomized trials with the change in CIMT reported as one of the end points. Summary estimates of weighted mean differences (WMDs) and 95% CIs were obtained by using random-effect models. Meta-regression and subgroup analyses were performed to identify the source of heterogeneity. RESULTS Our analysis showed that folic acid supplementation significantly reduces the progression of CIMT (WMD: -0.04 mm; 95%CI: -0.07, -0.02; P<0.001), particularly in subjects with chronic kidney disease (CKD) (WMD: -0.16 mm; 95%CI: -0.26, -0.07; P=0.0006) or high cardiovascular disease (CVD) risk (WMD: -0.05 mm; 95%CI: -0.11, 0.00; P=0.06) but not in subjects who were generally healthy with only elevated homocysteine concentrations (WMD:0.00 mm; 95%CI: -0.01, 0.01; P=0.35). Furthermore, meta-regression analysis of the data showed that the baseline CIMT levels (P=0.011) and the percent reduction of homocysteine (P<0.001) were positively related to the effect size. Consistently, a greater beneficial effect was seen in those trials with baseline CIMT levels ≥0.8 mm (WMD: -0.14 mm; 95%CI: -0.19, -0.08; P<0.0001), and a reduction in the homocysteine concentration ≥30% (WMD: -0.22 mm; 95%CI: -0.38, -0.06; P=0.009). In the corresponding comparison groups, the effect sizes were attenuated and insignificant. CONCLUSIONS Our findings indicate that folic acid supplementation is effective in reducing the progression of CIMT, particularly in subjects with CKD or high CVD risk and among trials with higher baseline CIMT levels or a larger homocysteine reduction.
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Affiliation(s)
- Xianhui Qin
- Institute of Biomedicine, Anhui Medical University, Hefei, China
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Zhou YH, Tang JY, Wu MJ, Lu J, Wei X, Qin YY, Wang C, Xu JF, He J. Effect of folic acid supplementation on cardiovascular outcomes: a systematic review and meta-analysis. PLoS One 2011; 6:e25142. [PMID: 21980387 PMCID: PMC3182189 DOI: 10.1371/journal.pone.0025142] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 08/26/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Folic acid is widely used to lower homocysteine concentrations and prevent adverse cardiovascular outcomes. However, the effect of folic acid on cardiovascular events is not clear at the present time. We carried out a comprehensive systematic review and meta-analysis to assess the effects of folic acid supplementation on cardiovascular outcomes. METHODOLOGY AND PRINCIPAL FINDINGS We systematically searched Medline, EmBase, the Cochrane Central Register of Controlled Trials, reference lists of articles, and proceedings of major meetings for relevant literature. We included randomized placebo-controlled trials that reported on the effects of folic acid on cardiovascular events compared to placebo. Of 1594 identified studies, we included 16 trials reporting data on 44841 patients. These studies reported 8238 major cardiovascular events, 2001 strokes, 2917 myocardial infarctions, and 6314 deaths. Folic acid supplementation as compared to placebo had no effect on major cardiovascular events (RR, 0.98; 95% CI, 0.93-1.04), stroke (RR, 0.89; 95% CI,0.78-1.01), myocardial infarction (RR, 1.00; 95% CI, 0.93-1.07), or deaths from any cause (RR, 1.00;95% CI, 0.96-1.05). Moreover, folic acid as compared to placebo also had no effect on the following secondary outcomes: risk of revascularization (RR, 1.05; 95%CI, 0.95-1.16), acute coronary syndrome (RR, 1.06; 95%CI, 0.97-1.15), cancer (RR, 1.08; 95%CI, 0.98-1.21), vascular death (RR, 0.94; 95%CI,0.88-1.02), or non-vascular death (RR, 1.06; 95%CI, 0.97-1.15). CONCLUSION/SIGNIFICANCE Folic acid supplementation does not effect on the incidence of major cardiovascular events, stroke, myocardial infarction or all cause mortality.
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Affiliation(s)
- Yu-Hao Zhou
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Jian-Yuan Tang
- Office of Compliance and Development, Center for Drug Evaluation, SFDA, Beijing, China
| | - Mei-Jing Wu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Jian Lu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Xin Wei
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying-Yi Qin
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Chao Wang
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Jin-Fang Xu
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Jia He
- Department of Health Statistics, Second Military Medical University, Shanghai, China
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ZSOM M, FÜLÖP T, ZSOM L, BARÁTH Á, MARÓTI Z, ENDREFFY E. Genetic polymorphisms and the risk of progressive renal failure in elderly Hungarian patients. Hemodial Int 2011; 15:501-8. [DOI: 10.1111/j.1542-4758.2011.00593.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 07/01/2011] [Indexed: 01/21/2023]
Affiliation(s)
| | - Tibor FÜLÖP
- Department of Internal Medicine; Division of Nephrology; University of Mississippi Medical Center; Jackson; Mississippi; USA
| | - Lajos ZSOM
- Department of Internal Medicine; Division of Nephrology; University of Mississippi Medical Center; Jackson; Mississippi; USA
| | - Ákos BARÁTH
- Department of Pediatrics and Child Health Center; Albert Szent-Györgyi Medical Center; Faculty of Medicine; University of Szeged; Szeged; Hungary
| | - Zoltán MARÓTI
- Department of Pediatrics and Child Health Center; Albert Szent-Györgyi Medical Center; Faculty of Medicine; University of Szeged; Szeged; Hungary
| | - Emőke ENDREFFY
- Department of Pediatrics and Child Health Center; Albert Szent-Györgyi Medical Center; Faculty of Medicine; University of Szeged; Szeged; Hungary
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Holt S, Goldsmith D. Renal Association Clinical Practice Guideline on cardiovascular disease in CKD. Nephron Clin Pract 2011; 118 Suppl 1:c125-44. [PMID: 21555891 DOI: 10.1159/000328065] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 08/06/2010] [Indexed: 11/19/2022] Open
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Qin X, Huo Y, Langman CB, Hou F, Chen Y, Matossian D, Xu X, Wang X. Folic acid therapy and cardiovascular disease in ESRD or advanced chronic kidney disease: a meta-analysis. Clin J Am Soc Nephrol 2010; 6:482-8. [PMID: 21088292 DOI: 10.2215/cjn.05310610] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The efficacy of folic acid therapy to lower homocysteine (Hcy) levels in an effort to reduce cardiovascular disease (CVD) risk in patients with ESRD or advanced chronic kidney disease (ACKD; creatinine clearance, <30 ml/min) remains inconclusive. We conducted a meta-analysis of relevant randomized trials to further examine this issue. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This meta-analysis included 3886 patients with ESRD/ACKD from seven qualified randomized trials using folic acid therapy and with CVD reported as one of the end points. RESULTS When pooling the seven trials, folic acid therapy reduced the risk of CVD by 15% (RR, 0.85; 95% CI, 0.76 to 0.96; P = 0.009). A greater beneficial effect was observed among those trials with a treatment duration >24 months (RR, 0.84; 95% CI, 0.72 to 0.98; P = 0.02), a decrease in Hcy level >20% (RR, 0.83; 95% CI, 0.73 to 0.95; P = 0.007), and no or partial folic acid fortification (RR, 0.80; 95% CI, 0.65 to 0.99; P = 0.04). The beneficial effect also was seen when Hcy levels decreased >20%, even in the presence of folic acid fortification (RR, 0.85; 95% CI, 0.73 to 0.99; P = 0.04). In the corresponding comparison groups, the estimated RRs were attenuated and insignificant. CONCLUSIONS Folic acid therapy can reduce CVD risk in patients with ESRD/ACKD by 15%. A greater beneficial effect was observed among those trials with no or partial folic acid fortification or a decrease in Hcy level >20% regardless of folic acid fortification.
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Affiliation(s)
- Xianhui Qin
- Institute of Biomedicine, Anhui Medical University, Hefei, China
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Schupp N, Heidland A, Stopper H. Genomic damage in endstage renal disease-contribution of uremic toxins. Toxins (Basel) 2010; 2:2340-58. [PMID: 22069557 PMCID: PMC3153169 DOI: 10.3390/toxins2102340] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 09/23/2010] [Accepted: 09/26/2010] [Indexed: 12/16/2022] Open
Abstract
Patients with end-stage renal disease (ESRD), whether on conservative, peritoneal or hemodialysis therapy, have elevated genomic damage in peripheral blood lymphocytes and an increased cancer incidence, especially of the kidney. The damage is possibly due to accumulation of uremic toxins like advanced glycation endproducts or homocysteine. However, other endogenous substances with genotoxic properties, which are increased in ESRD, could be involved, such as the blood pressure regulating hormones angiotensin II and aldosterone or the inflammatory cytokine TNF-α. This review provides an overview of genomic damage observed in ESRD patients, focuses on possible underlying causes and shows modulations of the damage by modern dialysis strategies and vitamin supplementation.
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Affiliation(s)
- Nicole Schupp
- Institute of Pharmacology and Toxicology, University of Würzburg, Versbacher Straße 9, 97078 Würzburg, Germany;
- Author to whom correspondence should be addressed; ; Tel.: +49-931-20148722; Fax: +49-931-20148446
| | - August Heidland
- Department of Internal Medicine, University of Würzburg, Josef-Schneider-Straße 2, 97080 Würzburg, Germany;
| | - Helga Stopper
- Institute of Pharmacology and Toxicology, University of Würzburg, Versbacher Straße 9, 97078 Würzburg, Germany;
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Ntaios G, Savopoulos C, Karamitsos D, Economou I, Destanis E, Chryssogonidis I, Pidonia I, Zebekakis P, Polatides C, Sion M, Grekas D, Hatzitolios A. The effect of folic acid supplementation on carotid intima-media thickness in patients with cardiovascular risk: A randomized, placebo-controlled trial. Int J Cardiol 2010; 143:16-9. [DOI: 10.1016/j.ijcard.2009.01.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Revised: 12/17/2008] [Accepted: 01/10/2009] [Indexed: 10/21/2022]
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Lee M, Hong KS, Chang SC, Saver JL. Efficacy of homocysteine-lowering therapy with folic Acid in stroke prevention: a meta-analysis. Stroke 2010; 41:1205-12. [PMID: 20413740 PMCID: PMC2909661 DOI: 10.1161/strokeaha.109.573410] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Although a lower serum homocysteine concentration is associated with a reduced risk of stroke in epidemiologic studies, randomized, controlled trials have yielded mixed findings regarding the effect of therapeutic homocysteine lowering on stroke prevention. We performed a meta-analysis of randomized, controlled trials to assess the efficacy of folic acid supplementation in the prevention of stroke. METHODS Salient trials were identified by formal literature search. Relative risk (RR) with 95% CI was used as a measure of the association between folic acid supplementation and risk of stroke, after pooling data across trials in a fixed-effects model. RESULTS The search identified 13 randomized, controlled trials that had enrolled 39 005 participants for folic acid therapy to reduce homocysteine in which stroke was reported as an outcome measure. Across all trials, folic acid supplementation was associated with a trend toward mild benefit that did not reach statistical significance in reducing the risk of stroke (RR=0.93; 95% CI, 0.85-1.03; P=0.16). The RR for nonsecondary prevention trials was 0.89 (95% CI, 0.79-0.99; P=0.03). In stratified analyses, a greater beneficial effect was seen in the trials testing combination therapy of folic acid plus vitamins B6 and B12 (RR=0.83; 95% CI, 0.71-0.97; P=0.02) and in the trials that disproportionately enrolled male patients (men:women >2; RR=0.84; 95% CI, 0.74-0.94; P=0.003). CONCLUSIONS Folic acid supplementation did not demonstrate a major effect in averting stroke. However, potential mild benefits in primary stroke prevention, especially when folate is combined with B vitamins and in male patients, merit further investigation.
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Affiliation(s)
- Meng Lee
- UCLA Stroke Center, 710 Westwood Plaza, Los Angeles, CA 90095, USA
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Buhr G, Bales CW. Nutritional Supplements for Older Adults: Review and Recommendations—Part II. ACTA ACUST UNITED AC 2010; 29:42-71. [DOI: 10.1080/01639360903586464] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Gwendolen Buhr
- a Department of Medicine , Duke University Medical Center , Durham, North Carolina, USA
| | - Connie W. Bales
- a Department of Medicine , Duke University Medical Center , Durham, North Carolina, USA
- b GRECC, Durham VA Medical Center , Duke University Medical Center , Durham, North Carolina, USA
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Martí-Carvajal AJ, Solà I, Lathyris D, Salanti G. Homocysteine lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev 2009:CD006612. [PMID: 19821378 PMCID: PMC4164174 DOI: 10.1002/14651858.cd006612.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cardiovascular disease such as coronary artery disease, stroke and congestive heart failure, is a leading cause of death worldwide. A postulated risk factor is elevated circulating total homocysteine (tHcy) levels which is influenced mainly by blood levels of cyanocobalamin (vitamin B12), folic acid (vitamin B9) and pyridoxine (vitamin B6). There is uncertainty regarding the strength of association between tHcy and the risk of cardiovascular disease. OBJECTIVES To assess the clinical effectiveness of homocysteine-lowering interventions (HLI) in people with or without pre-existing cardiovascular disease. SEARCH STRATEGY We searched The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (issue 3 2008), MEDLINE (1950 to August 2008), EMBASE (1988 to August 2008), and LILACS (1982 to September 2, 2008). We also searched in Allied and Complementary Medicine (AMED; 1985 to August 2008), ISI Web of Science (1993 to August 2008), and the Cochrane Stroke Group Specialised Register (April 2007). We hand searched pertinent journals and the reference lists of included papers. We also contacted researchers in the field. There was no language restriction in the search. SELECTION CRITERIA We included randomised clinical trials (RCTs) assessing the effects of HLI for preventing cardiovascular events with a follow-up period of 1 year or longer. We considered myocardial infarction and stroke as the primary outcomes. We excluded studies in patients with end-stage renal disease. DATA COLLECTION AND ANALYSIS We independently performed study selection, risk of bias assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using I(2). We used a random-effects model to synthesise the findings. MAIN RESULTS We included eight RCTs involving 24,210 participants with a low risk of bias in general terms. HLI did not reduce the risk of non-fatal or fatal myocardial infarction, stroke, or death by any cause (pooled RR 1.03, 95% CI 0.94 to 1.13, I(2) = 0%; pooled RR 0.89, 95% CI 0.73 to 1.08, I(2) = 15%); and pooled RR 1.00 (95% CI 0.92 to 1.09, I(2): 0%), respectively. AUTHORS' CONCLUSIONS Results from available published trials suggest that there is no evidence to support the use of HLI to prevent cardiovascular events.
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Affiliation(s)
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Georgia Salanti
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina 45110, Greece
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Apeland T, Kristensen O, Mansoor MA. The aminothiol redox status in haemodialysis patients does not improve with folate therapy. Scandinavian Journal of Clinical and Laboratory Investigation 2009; 69:265-71. [DOI: 10.1080/00365510802521143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Nigwekar SU, Cass A, Gallagher MP, Jardine MJ, Kang A, Kulshrestha S, Navaneethan SD, Perkovic V, Strippoli GFM, Zoungas S. Interventions for lowering plasma homocysteine levels in dialysis patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd004683.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Heinz J, Kropf S, Luley C, Dierkes J. Homocysteine as a risk factor for cardiovascular disease in patients treated by dialysis: a meta-analysis. Am J Kidney Dis 2009; 54:478-89. [PMID: 19359080 DOI: 10.1053/j.ajkd.2009.01.266] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 01/21/2009] [Indexed: 11/11/2022]
Abstract
BACKGROUND In the general population, increased homocysteine concentrations are a risk factor for cardiovascular disease and mortality. However, it is not known whether this also applies to patients with end-stage renal disease. STUDY DESIGN Meta-analysis of retrospective (11 studies including 1,506 individuals), prospective observational studies (12 studies including 1,975 individuals), and intervention trials (5 studies including 1,642 dialysis patients). Analyses were carried out separately, according to the study design. SETTING & POPULATION Studies of patients with end-stage renal disease treated by means of hemodialysis or peritoneal dialysis. SELECTION CRITERIA FOR STUDIES Studies investigating the association between total homocysteine level and cardiovascular disease or total mortality or the influence of vitamin supplementation on cardiovascular or mortality risk. INTERVENTION In intervention studies, vitamin preparations with folic acid alone or in combination with other vitamins, such as vitamin B(12) and B(6), were used. OUTCOMES In retrospective studies, cases are patients with cardiovascular diseases. Outcomes for prospective observational and intervention studies are cardiovascular events and total mortality. RESULTS In retrospective studies, there was no significant overall difference in homocysteine concentrations between cases and controls (weighted mean difference in homocysteine, 2.82 micromol/L; 95% confidence interval [CI], -2.22 to 7.86; P = 0.3). The pooled overall risk estimate for prospective observational studies suggests no association between homocysteine level (5-micromol/L increase) and total mortality (hazard ratio [HR], 1.02; 95% CI, 0.93 to 1.12; P = 0.7), but there was an association with cardiovascular events (HR, 1.09; 95% CI, 1.03 to 1.14; P = 0.001). In subgroup analysis of patients not receiving vitamins, an increase in homocysteine level was associated with increased mortality (HR, 1.07; 95% CI, 1.02 to 1.13; P = 0.01). For intervention trials with B vitamins, there was a significant risk reduction for cardiovascular disease (relative risk, 0.73; 95% CI, 0.56 to 0.94; P = 0.02), but no risk reduction for total mortality or the composite end point including total mortality (relative risk, 1.01; 95% CI, 0.88 to 1.15; P = 0.9). LIMITATIONS Many studies are small, which may lead to the observed heterogeneity. Some intervention trials are neither placebo controlled nor randomized. Separate analyses for specific end points and patients treated by means of hemodialysis or peritoneal dialysis were not possible. CONCLUSION Total homocysteine level may be a risk factor for cardiovascular events and total mortality in patients with end-stage renal disease not receiving vitamin supplementation or folic acid food fortification. There may be a potential for reducing cardiovascular disease in this population by folic acid supplementation.
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Affiliation(s)
- Judith Heinz
- Institute of Clinical Chemistry and Pathobiochemistry, University Hospital Magdeburg, Magdeburg, Germany.
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Heerspink HJL, Ninomiya T, Zoungas S, de Zeeuw D, Grobbee DE, Jardine MJ, Gallagher M, Roberts MA, Cass A, Neal B, Perkovic V. Effect of lowering blood pressure on cardiovascular events and mortality in patients on dialysis: a systematic review and meta-analysis of randomised controlled trials. Lancet 2009; 373:1009-15. [PMID: 19249092 PMCID: PMC2659734 DOI: 10.1016/s0140-6736(09)60212-9] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Patients undergoing dialysis have a substantially increased risk of cardiovascular mortality and morbidity. Although several trials have shown the cardiovascular benefits of lowering blood pressure in the general population, there is uncertainty about the efficacy and tolerability of reducing blood pressure in patients on dialysis. We did a systematic review and meta-analysis to assess the effect of blood pressure lowering in patients on dialysis. METHODS We systematically searched Medline, Embase, and the Cochrane Library database for trials reported between 1950 and November, 2008, without language restriction. We extracted a standardised dataset from randomised controlled trials of blood pressure lowering in patients on dialysis that reported cardiovascular outcomes. Meta-analysis was done with a random effects model. FINDINGS We identified eight relevant trials, which provided data for 1679 patients and 495 cardiovascular events. Weighted mean systolic blood pressure was 4.5 mm Hg lower and diastolic blood pressure 2.3 mm Hg lower in actively treated patients than in controls. Blood pressure lowering treatment was associated with lower risks of cardiovascular events (RR 0.71, 95% CI 0.55-0.92; p=0.009), all-cause mortality (RR 0.80, 0.66-0.96; p=0.014), and cardiovascular mortality (RR 0.71, 0.50-0.99; p=0.044) than control regimens. The effects seem to be consistent across a range of patient groups included in the studies. INTERPRETATION Treatment with agents that lower blood pressure should routinely be considered for individuals undergoing dialysis to reduce the very high cardiovascular morbidity and mortality rate in this population.
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Affiliation(s)
- Hiddo J Lambers Heerspink
- George Institute for International Health, University of Sydney, Sydney, Australia
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Toshiharu Ninomiya
- George Institute for International Health, University of Sydney, Sydney, Australia
| | - Sophia Zoungas
- George Institute for International Health, University of Sydney, Sydney, Australia
- University of Monash, Melbourne, VIC, Australia
| | - Dick de Zeeuw
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Diederick E Grobbee
- George Institute for International Health, University of Sydney, Sydney, Australia
- Julius Center for Health Science and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Meg J Jardine
- George Institute for International Health, University of Sydney, Sydney, Australia
| | - Martin Gallagher
- George Institute for International Health, University of Sydney, Sydney, Australia
| | - Matthew A Roberts
- Department of Nephrology, Austin Health, VIC, Australia
- Department of Medicine, University of Melbourne, VIC, Australia
| | - Alan Cass
- George Institute for International Health, University of Sydney, Sydney, Australia
| | - Bruce Neal
- George Institute for International Health, University of Sydney, Sydney, Australia
| | - Vlado Perkovic
- George Institute for International Health, University of Sydney, Sydney, Australia
- Correspondence to: Dr Vlado Perkovic, George Institute for International Health, University of Sydney, PO Box M201, Missenden Road, Sydney, NSW 2050, Australia
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Panayiotou A, Nicolaides A, Griffin M, Tyllis T, Georgiou N, Martin RM, Bond D, Tziakouri-Shiakalli C, Fessas C, Deltas C. Serum total homocysteine, folate, 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C-->T genotype and subclinical atherosclerosis. Expert Opin Ther Targets 2009; 13:1-11. [PMID: 19063701 DOI: 10.1517/14728220802560281] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine the relationship of serum total homocysteine (tHcy), serum folate and 5,10-methylenetetrahydrofolate reductase (MTHFR) 677C-->T genotype with ultrasonic arterial wall measurements associated with subclinical atherosclerosis. STUDY DESIGN Cross-sectional analysis of 767 participants in an ongoing prospective study. Intima-media thickness (IMT) of the common carotid (IMTcc), IMT of the internal carotid including plaque when present (IMT(max)) and the sum of the thickest plaques present in both carotid and both common femoral bifurcations (total plaque thickness (TPT)) were measured using ultrasound. RESULTS People in the upper homocysteine quartile were more likely to have clinical cardiovascular disease (CVD) than those in the lowest three quartiles. They were also more likely to have plaques. The MTHFR 677C-->T genotype was not associated with any of the measures of subclinical atherosclerosis in either men or women but was the most important determinant of total homocysteine levels in men under 60 years of age. CONCLUSIONS Increased homocysteine levels but not MTHFR 677C-->T genotype, are associated with subclinical atherosclerosis and the presence of plaques. Our results indicate that measurements of blood levels of homocysteine and folate in people at intermediate risk for atherosclerotic CVD before symptoms occur, might improve risk stratification and facilitate the decision to provide folate/B vitamin intervention in primary prevention.
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Affiliation(s)
- Andrie Panayiotou
- University of Cyprus, Department of Biological Sciences, PO Box 20537, 1678, Nicosia, Cyprus.
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Abstract
Atherosclerosis is a systemic disease that is responsible for most cardiovascular events and stroke. Epidemiologic studies and intervention trials based on the incidence of acute vascular disease end points require years of follow-up, the participation of large populations, or both. As a consequence, such studies consume considerable time and financial resources. The use of surrogate markers, therefore, is of paramount relevance because it allows researchers to have reliable data in less time and from reduced populations. Intima-media thickness (IMT) measured by B-mode ultrasound is the most studied surrogate marker and has been validated by official medical agencies. In this article, we review the most important technical considerations related to its measurement and highlight issues that should be systematically addressed in IMT-related studies. In summary, the use of IMT as an end point in clinical studies is of great value, but several technical limitations might jeopardize its interpretation.
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