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

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.

Cardiovascular risk factors following renal transplant

“…Neither treatment reduced composite CVD outcome, allcause mortality, or dialysisdependent kidney failure despite significant reduction in homocysteine level [120] . These results are supported by a recent review which concluded that folic acid based homocysteine lowering does not reduce CV events in people with kidney disease and therefore folic acid based regimens should not be used for the prevention of CV events in people with hyperhomocysteinaemia and kidney disease [121] .…”

The Predictors of Left Ventricular Hypertrophy in Kidney Transplant Recipients

“…Studies showed that in the general population, a 25% lower homocysteine level is associated with a 11% lower risk of coronary artery disease and a 19% lower risk of stroke (34,35). Furthermore, Veeranna et al showed that adding homocysteine levels to the Framingham risk score enhances the prediction of risk in individuals at intermediate CVD risk (36).…”

Updating the lipids hypothesis of inflammation and vascular disease in patients with chronic kidney disease: a stearoyl‐CoA desaturase affair?

“…Because of the disappointing results of intervention trials aimed at curbing the high mortality in CKD-5D patients [18,21,22], renal physicians should increase efforts to test biologically sound interventions that may attenuate the enormous cardiovascular and noncardiovascular risk differential between patients with kidney failure and the general population. In this respect, the hypothesis proposed by Huang et al [20] would certainly be worth testing.…”