• Meg J Jardine, Amy Kang, Sophia Zoungas, Sankar D Navaneethan, Toshiharu Ninomiya, Sagar U Nigwekar, Martin P Gallagher, Alan Cass, Giovanni Strippoli, and Vlado Perkovic.
• George Institute for Global Health, PO Box M201, Camperdown, NSW 2050, Australia. mjardine@georgeinstitute.org.au
• BMJ. 2012 Jan 1;344:e3533.

ObjectiveTo systematically review the effect of folic acid based homocysteine lowering on cardiovascular outcomes in people with kidney disease.DesignSystematic review and meta-analysis.Data SourcesMedline, Embase, the Cochrane Library, and ClinicalTrials.gov to June 2011.Study SelectionRandomised 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 ExtractionTwo 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.Results11 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.ConclusionsFolic 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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