Sunil V Badve1, Suetonia C Palmer2, Giovanni F M Strippoli3, Matthew A Roberts4, Armando Teixeira-Pinto5, Neil Boudville6, Alan Cass7, Carmel M Hawley8, Swapnil S Hiremath9, Elaine M Pascoe10, Vlado Perkovic11, Gillian A Whalley12, Jonathan C Craig13, David W Johnson8. 1. Australasian Kidney Trials Network, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia; Department of Nephrology, St. George Hospital, Sydney, Australia; The George Institute for Global Health, University of Sydney, Sydney, Australia. Electronic address: sbadve@georgeinstitute.org.au. 2. Australasian Kidney Trials Network, Brisbane, Australia; Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand. 3. School of Public Health, University of Sydney, Sydney, Australia; Diaverum Scientific Office and Diaverum Academy, Lund, Sweden; Department of Emergency and Organ Transplantation, University of Bari, Italy. 4. Australasian Kidney Trials Network, Brisbane, Australia; Department of Renal Medicine, Eastern Health Clinical School, Monash University, Melbourne, Australia. 5. School of Public Health, University of Sydney, Sydney, Australia. 6. Australasian Kidney Trials Network, Brisbane, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Australia. 7. Australasian Kidney Trials Network, Brisbane, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, Australia. 8. Australasian Kidney Trials Network, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia. 9. Division of Nephrology, University of Ottawa, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada. 10. Australasian Kidney Trials Network, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia. 11. Australasian Kidney Trials Network, Brisbane, Australia; The George Institute for Global Health, University of Sydney, Sydney, Australia. 12. Unitec Institute of Technology, Auckland, New Zealand. 13. Australasian Kidney Trials Network, Brisbane, Australia; School of Public Health, University of Sydney, Sydney, Australia; Cochrane Kidney and Transplant Group, Sydney, Australia.
Abstract
BACKGROUND: Left ventricular mass (LVM) is a widely used surrogate end point in randomized trials involving people with chronic kidney disease (CKD) because treatment-induced LVM reductions are assumed to lower cardiovascular risk. The aim of this study was to assess the validity of LVM as a surrogate end point for all-cause and cardiovascular mortality in CKD. STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Participants with any stages of CKD. SELECTION CRITERIA FOR STUDIES: Randomized controlled trials with 3 or more months' follow-up that reported LVM data. INTERVENTION: Any pharmacologic or nonpharmacologic intervention. OUTCOMES: The surrogate outcome of interest was LVM change from baseline to last measurement, and clinical outcomes of interest were all-cause and cardiovascular mortality. Standardized mean differences (SMDs) of LVM change and relative risk for mortality were estimated using pairwise random-effects meta-analysis. Correlations between surrogate and clinical outcomes were summarized across all interventions combined using bivariate random-effects Bayesian models, and 95% credible intervals were computed. RESULTS: 73 trials (6,732 participants) covering 25 intervention classes were included in the meta-analysis. Overall, risk of bias was uncertain or high. Only 3 interventions reduced LVM: erythropoiesis-stimulating agents (9 trials; SMD, -0.13; 95% CI, -0.23 to -0.03), renin-angiotensin-aldosterone system inhibitors (13 trials; SMD, -0.28; 95% CI, -0.45 to -0.12), and isosorbide mononitrate (2 trials; SMD, -0.43; 95% CI, -0.72 to -0.14). All interventions had uncertain effects on all-cause and cardiovascular mortality. There were weak and imprecise associations between the effects of interventions on LVM change and all-cause (32 trials; 5,044 participants; correlation coefficient, 0.28; 95% credible interval, -0.13 to 0.59) and cardiovascular mortality (13 trials; 2,327 participants; correlation coefficient, 0.30; 95% credible interval, -0.54 to 0.76). LIMITATIONS: Limited long-term data, suboptimal quality of included studies. CONCLUSIONS: There was no clear and consistent association between intervention-induced LVM change and mortality. Evidence for LVM as a valid surrogate end point in CKD is currently lacking. Crown
BACKGROUND:Left ventricular mass (LVM) is a widely used surrogate end point in randomized trials involving people with chronic kidney disease (CKD) because treatment-induced LVM reductions are assumed to lower cardiovascular risk. The aim of this study was to assess the validity of LVM as a surrogate end point for all-cause and cardiovascular mortality in CKD. STUDY DESIGN: Systematic review and meta-analysis. SETTING & POPULATION: Participants with any stages of CKD. SELECTION CRITERIA FOR STUDIES: Randomized controlled trials with 3 or more months' follow-up that reported LVM data. INTERVENTION: Any pharmacologic or nonpharmacologic intervention. OUTCOMES: The surrogate outcome of interest was LVM change from baseline to last measurement, and clinical outcomes of interest were all-cause and cardiovascular mortality. Standardized mean differences (SMDs) of LVM change and relative risk for mortality were estimated using pairwise random-effects meta-analysis. Correlations between surrogate and clinical outcomes were summarized across all interventions combined using bivariate random-effects Bayesian models, and 95% credible intervals were computed. RESULTS: 73 trials (6,732 participants) covering 25 intervention classes were included in the meta-analysis. Overall, risk of bias was uncertain or high. Only 3 interventions reduced LVM: erythropoiesis-stimulating agents (9 trials; SMD, -0.13; 95% CI, -0.23 to -0.03), renin-angiotensin-aldosterone system inhibitors (13 trials; SMD, -0.28; 95% CI, -0.45 to -0.12), and isosorbide mononitrate (2 trials; SMD, -0.43; 95% CI, -0.72 to -0.14). All interventions had uncertain effects on all-cause and cardiovascular mortality. There were weak and imprecise associations between the effects of interventions on LVM change and all-cause (32 trials; 5,044 participants; correlation coefficient, 0.28; 95% credible interval, -0.13 to 0.59) and cardiovascular mortality (13 trials; 2,327 participants; correlation coefficient, 0.30; 95% credible interval, -0.54 to 0.76). LIMITATIONS: Limited long-term data, suboptimal quality of included studies. CONCLUSIONS: There was no clear and consistent association between intervention-induced LVM change and mortality. Evidence for LVM as a valid surrogate end point in CKD is currently lacking. Crown
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