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Dental Materials : Official Publication... Aug 2022The loss of the dental coronal portion following carious lesions or fractures leads to endodontic treatment with subsequent restoration to ensure correct anatomy and... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The loss of the dental coronal portion following carious lesions or fractures leads to endodontic treatment with subsequent restoration to ensure correct anatomy and function. Recently, partial adhesive restorations have been widely proposed to increase the survival rate of endodontically treated teeth. The primary purpose of this review is to assess the failure rate of indirect partial adhesive restorations on endodontically treated teeth (ETT), considering the follow-up period.
METHODS
The indications reported in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) were used to draft the present review. The study was constructed on PICO questions: population (patients who need indirect adhesive restorative treatment on endodontically treated teeth with onlay and overlay), intervention (onlay and overlay), control (patients with onlay and overlay on endodontically treated teeth) and outcome (failure rate and types of failure for onlay and overlay). The asked scientific question was: what are the failure rate and types of failure for adhesive indirect partial restorations on ETT?
RESULTS
The overall failure rate that emerges is 0.087 with a ratio of 121/1254, I 80 % p-value< 0.001. Moreover, by meta-regression with covariates the follow-up period reports a coefficient of 0.013 with a P-value< 0.001. In conclusion, the indirect partial restorations on endodontically treated teeth displayed overall acceptable outcomes in terms of success from 2 to 4 years after their placement with only 4.32 % of failure. Failures increase after 7 years up to 12-30 years with failure rates of approximatively 10.65 % and 20.94 %. The analysis of the included articles reporting the causes of restorations failures showed that 15.51 % of cases were related to the loss of dental element.
SIGNIFICANCE
Besides the survival rates of indirect adhesive restorations on endodontically treated posterior teeth, it was highlighted that the majority of failures appeared restorable. Thus, partial restorations seemed able to prevent the ETT tooth loss.
Topics: Composite Resins; Dental Restoration Failure; Dental Restoration, Permanent; Humans; Inlays; Prognosis; Tooth, Nonvital
PubMed: 35835608
DOI: 10.1016/j.dental.2022.06.018 -
Clinical and Experimental Dental... Feb 2022The purpose of this systematic review and meta-analysis was to compare implant-supported removable partial dentures (ISRPDs) with distal extension removable partial... (Meta-Analysis)
Meta-Analysis Review
Implant-supported removable partial dentures compared to conventional dentures: A systematic review and meta-analysis of quality of life, patient satisfaction, and biomechanical complications.
OBJECTIVES
The purpose of this systematic review and meta-analysis was to compare implant-supported removable partial dentures (ISRPDs) with distal extension removable partial dentures (DERPDs) in terms of patient-reported outcome measures (PROMs: patients' quality of life and satisfaction) and to determine mechanical and biological complications associated with ISRPDs.
MATERIAL AND METHODS
An electronic search was performed on four databases to identify studies treating Kennedy class I or II edentulous patients and which compared ISRPDs with DERPDs in terms of PROMS and studies, which evaluated mechanical and biological complications associated ISRPDs. Two authors independently extracted data on quality of life, patient satisfaction, and biomechanical complications from these studies. The risk of bias was assessed for each study, and for PROMs, the authors performed a meta-analysis by using a random-effects model.
RESULTS
Thirteen articles were included based on the selection criteria. The difference in mean scores for quality of life (30.5 ± 1.8; 95% confidence interval [CI], 24.9-36.1) and patient satisfaction (-20.8 ± 0.2; 95% CI, -23.7 to -17.8) between treatments with conventional and implant-supported removable dentures was statistically significant (p < .05). Implant-supported removable dentures improved patients' overall quality of life and satisfaction. Some mechanical and biological complications, such as clasp adjustment, abutment or implant loosening, marginal bone resorption, and peri-implant mucositis, were noted in ISRPDs during patient follow-up. Studies assessing PROMs were very heterogeneous (I = 65%, p = .85; I = 75%, p = .88).
CONCLUSIONS
ISRPDs significantly improved quality of life and patient satisfaction. Some mechanical and biological complications have been associated with ISRPDs treatment, requiring regular monitoring of patients to avoid the occurrence of these complications.
Topics: Dental Implants; Dental Prosthesis, Implant-Supported; Denture, Partial, Removable; Humans; Patient Satisfaction; Quality of Life
PubMed: 35014207
DOI: 10.1002/cre2.521 -
The Cochrane Database of Systematic... Jun 2019This is an updated version of the original Cochrane review, published in 2015.Focal epilepsies are caused by a malfunction of nerve cells localised in one part of one... (Meta-Analysis)
Meta-Analysis
BACKGROUND
This is an updated version of the original Cochrane review, published in 2015.Focal epilepsies are caused by a malfunction of nerve cells localised in one part of one cerebral hemisphere. In studies, estimates of the number of individuals with focal epilepsy who do not become seizure-free despite optimal drug therapy vary between at least 20% and up to 70%. If the epileptogenic zone can be located, surgical resection offers the chance of a cure with a corresponding increase in quality of life.
OBJECTIVES
The primary objective is to assess the overall outcome of epilepsy surgery according to evidence from randomised controlled trials.Secondary objectives are to assess the overall outcome of epilepsy surgery according to non-randomised evidence, and to identify the factors that correlate with remission of seizures postoperatively.
SEARCH METHODS
For the latest update, we searched the following databases on 11 March 2019: Cochrane Register of Studies (CRS Web), which includes the Cochrane Epilepsy Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid, 1946 to March 08, 2019), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP).
SELECTION CRITERIA
Eligible studies were randomised controlled trials (RCTs) that included at least 30 participants in a well-defined population (age, sex, seizure type/frequency, duration of epilepsy, aetiology, magnetic resonance imaging (MRI) diagnosis, surgical findings), with an MRI performed in at least 90% of cases and an expected duration of follow-up of at least one year, and reporting an outcome related to postoperative seizure control. Cohort studies or case series were included in the previous version of this review.
DATA COLLECTION AND ANALYSIS
Three groups of two review authors independently screened all references for eligibility, assessed study quality and risk of bias, and extracted data. Outcomes were proportions of participants achieving a good outcome according to the presence or absence of each prognostic factor of interest. We intended to combine data with risk ratios (RRs) and 95% confidence intervals (95% CIs).
MAIN RESULTS
We identified 182 studies with a total of 16,855 included participants investigating outcomes of surgery for epilepsy. Nine studies were RCTs (including two that randomised participants to surgery or medical treatment (99 participants included in the two trials received medical treatment)). Risk of bias in these RCTs was unclear or high. Most of the remaining 173 non-randomised studies followed a retrospective design. We assessed study quality using the Effective Public Health Practice Project (EPHPP) tool and determined that most studies provided moderate or weak evidence. For 29 studies reporting multivariate analyses, we used the Quality in Prognostic Studies (QUIPS) tool and determined that very few studies were at low risk of bias across domains.In terms of freedom from seizures, two RCTs found surgery (n = 97) to be superior to medical treatment (n = 99); four found no statistically significant differences between anterior temporal lobectomy (ATL) with or without corpus callosotomy (n = 60), between subtemporal or transsylvian approach to selective amygdalohippocampectomy (SAH) (n = 47); between ATL, SAH and parahippocampectomy (n = 43) or between 2.5 cm and 3.5 cm ATL resection (n = 207). One RCT found total hippocampectomy to be superior to partial hippocampectomy (n = 70) and one found ATL to be superior to stereotactic radiosurgery (n = 58); and another provided data to show that for Lennox-Gastaut syndrome, no significant differences in seizure outcomes were evident between those treated with resection of the epileptogenic zone and those treated with resection of the epileptogenic zone plus corpus callosotomy (n = 43). We judged evidence from the nine RCTs to be of moderate to very low quality due to lack of information reported about the randomised trial design and the restricted study populations.Of the 16,756 participants included in this review who underwent a surgical procedure, 10,696 (64%) achieved a good outcome from surgery; this ranged across studies from 13.5% to 92.5%. Overall, we found the quality of data in relation to recording of adverse events to be very poor.In total, 120 studies examined between one and eight prognostic factors in univariate analysis. We found the following prognostic factors to be associated with a better post-surgical seizure outcome: abnormal pre-operative MRI, no use of intracranial monitoring, complete surgical resection, presence of mesial temporal sclerosis, concordance of pre-operative MRI and electroencephalography, history of febrile seizures, absence of focal cortical dysplasia/malformation of cortical development, presence of tumour, right-sided resection, and presence of unilateral interictal spikes. We found no evidence that history of head injury, presence of encephalomalacia, presence of vascular malformation, and presence of postoperative discharges were prognostic factors of outcome.Twenty-nine studies reported multi-variable models of prognostic factors, and showed that the direction of association of factors with outcomes was generally the same as that found in univariate analyses.We observed variability in many of our analyses, likely due to small study sizes with unbalanced group sizes and variation in the definition of seizure outcome, the definition of prognostic factors, and the influence of the site of surgery AUTHORS' CONCLUSIONS: Study design issues and limited information presented in the included studies mean that our results provide limited evidence to aid patient selection for surgery and prediction of likely surgical outcomes. Future research should be of high quality, follow a prospective design, be appropriately powered, and focus on specific issues related to diagnostic tools, the site-specific surgical approach, and other issues such as extent of resection. Researchers should investigate prognostic factors related to the outcome of surgery via multi-variable statistical regression modelling, where variables are selected for modelling according to clinical relevance, and all numerical results of the prognostic models are fully reported. Journal editors should not accept papers for which study authors did not record adverse events from a medical intervention. Researchers have achieved improvements in cancer care over the past three to four decades by answering well-defined questions through the conduct of focused RCTs in a step-wise fashion. The same approach to surgery for epilepsy is required.
Topics: Adolescent; Adult; Analysis of Variance; Anticonvulsants; Child; Epilepsies, Partial; Female; Hippocampus; Humans; Male; Prognosis; Randomized Controlled Trials as Topic; Retrospective Studies; Treatment Outcome
PubMed: 31237346
DOI: 10.1002/14651858.CD010541.pub3 -
Journal of Clinical Medicine Dec 2020(1) Background: Even though rotator cuff tears are the most frequent tendon injuries in adults, the effectiveness of conservatively treated partial-thickness tears still... (Review)
Review
(1) Background: Even though rotator cuff tears are the most frequent tendon injuries in adults, the effectiveness of conservatively treated partial-thickness tears still remains a matter of debate. The purpose of this review is to compare corticosteroid injections to other drugs in the treatment of partial rotator cuff tears, focusing on the effectiveness of this therapeutic modality in terms of pain and shoulder functionality. (2) Methods: A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. All studies comparing the use of corticosteroids and other infiltrative techniques in the treatment of partial lesions (excluding studies that considered subacromial impingement as inclusion criteria) were pooled, data were extracted and statistically analyzed. (3) Results: Nine studies were included in this systematic review. Those studies, composed by a total of 494 shoulders treated, have been published from 1985 to 2019. All compared techniques have shown a significant improvement over baseline condition. PRP (Platelet Rich Plasma) injections have been shown to be significantly more effective in both functional and pain control only in the long term. (4) Conclusions: None of the techniques prevail indisputably on the others. Anyway, the treatment of partial rotator cuff tears with PRP injections seems to lead to significantly better outcomes in terms of pain and shoulder function in long term follow up. Whereas in short and medium term follow up, PRP injections was superior only in terms of shoulder function. The small number of studies on prolotherapy did not enable us to provide an opinion on the outcomes of this technique.
PubMed: 33375716
DOI: 10.3390/jcm10010051 -
Journal of Minimally Invasive Gynecology Apr 2022The aim of this systematic review with meta-analysis is to evaluate the impact of hysteroscopic metroplasty on adverse reproductive outcomes such as miscarriage, preterm... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The aim of this systematic review with meta-analysis is to evaluate the impact of hysteroscopic metroplasty on adverse reproductive outcomes such as miscarriage, preterm birth, and fetal malpresentation in patients with history of infertility or previous poor obstetrical outcomes.
DATA SOURCES
A systematic electronic search from inception each database up to April 2021 including the following databases was conducted: PubMed-MEDLINE, EMBASE, Web of Science, The Cochrane Library, the CGF Specialized Register of Controlled Trials, Google Scholar, and trial registries. A combination of the following keywords was used: uterine septum, septate uterus, congenital uterine malformation, class 2 uterus, class V uterus, metroplasty, hysteroscopic, pregnancy, clinical pregnancy, ongoing pregnancy, miscarriage, live birth, preterm birth, cesarean section, 'cesarean delivery, and fetal malpresentation.
METHODS OF STUDY SELECTION
Studies comparing reproductive outcomes between women undergoing hysteroscopic resection of the uterine septum and those with expectant management were included. Eligible population consisted of infertile women, women with poor obstetrical history, or women without previous pregnancy failures and a diagnosis of septate uterus.
TABULATION, INTEGRATION, AND RESULTS
The systematic electronic search retrieved 1076 studies; after elimination of duplicates, 688 titles and abstracts were screened, and 55 were assessed for eligibility. Eleven studies were included in the quantitative synthesis: one randomized controlled trial and 10 observational studies involving reproductive outcomes from 1589 patients with either complete or partial uterine septum. The pooled OR for miscarriage was 0.45, (95% CI, 0.22-0.90). When the analysis was performed considering subgroups according to the type of septum, pooled OR in complete septum subgroup was 0.16 (95% CI, 0.03-0.78), OR = 0.36 (95% CI, 0.19-0.71) in the partial septum subgroup and 0.58 (95% CI, 0.20-1.67) in those studies not differentiating between complete or partial septum. No significant differences were found between the 2 groups in OR of clinical pregnancy, term live birth, or risk of cesarean delivery. There was a significant decrease in the frequency of preterm birth in patients who underwent partial septum resection (OR = 0.30, 95% CI, 0.11-0.79). This difference was detected neither in patients with complete septum nor in studies not differentiating between partial or complete septum. The risk of fetal malpresentation was also significantly reduced (OR = 0.32, 95% CI, 0.16-0.65).
CONCLUSION
The results of the present meta-analysis support that hysteroscopic metroplasty is effective in reducing the risk of miscarriage in patients with complete or partial uterine septum, although these data should be confirmed with a well-designed randomized controlled trial.
Topics: Abortion, Spontaneous; Cesarean Section; Female; Humans; Hysteroscopy; Infant, Newborn; Infertility, Female; Pregnancy; Premature Birth; Uterus
PubMed: 34648934
DOI: 10.1016/j.jmig.2021.10.001 -
BMC Musculoskeletal Disorders Apr 2022The incidence of anterior cruciate ligament (ACL) injuries represents a large burden of knee injuries in both the general and sporting populations, often requiring...
BACKGROUND
The incidence of anterior cruciate ligament (ACL) injuries represents a large burden of knee injuries in both the general and sporting populations, often requiring surgical intervention. Although there is much research on complete ACL tears including outcomes and indications for surgery, little is known about the short- and long-term outcomes of non-operative, physiotherapy led intervention in partial ACL tears. The primary aim of this study was to evaluate studies looking at the effectiveness of physiotherapy led interventions in improving pain and function in young and middle-aged adults with partial ACL tears. Additionally, the secondary aim was to evaluate the completeness of exercise prescription in randomised trials for physiotherapy led interventions in the management in partial ACL tears.
METHODS
A comprehensive and systematic search was performed on six databases (Medline, CINAHL, EMBASE, PEDro, Scopus, SPORTDiscus and Cochrane). The search strategy consisted of two main concepts: (i) partial ACL tears, and (ii) non-operative management. 7,587 papers were identified by the search. After screening of eligible articles by two independent reviewers, 2 randomised studies were included for analysis. The same two reviewers assessed the completeness of reporting using the Toigio and Boutellier mechanobiological exercise descriptions and Template for Intervention Description and Replication (TIDieR) checklist. Group mean standard deviations (SD) for the main outcomes was extracted from both papers for analysis. Prospero Registration Number: CRD42020179892.
RESULTS
The search strategy identified two studies; one looking at Tai Chi and the other Pilates. The analysis indicated that Tai Chi was significant in reducing pain scores and both Tai Chi and Pilates were found to increase Muscle Peak Torque Strength (MPTS) at 180 degrees. Furthermore, Tai Chi showed a significant increase in proprioception.
CONCLUSIONS
Physiotherapy led interventions such as Pilates, and Tai Chi may improve pain, proprioception and strength in young and middle-aged adults with partial ACL tears, however full scale, high-quality randomised studies are required with long term outcomes recorded.
Topics: Adult; Anterior Cruciate Ligament Injuries; Anterior Cruciate Ligament Reconstruction; Exercise Movement Techniques; Humans; Middle Aged; Pain; Physical Therapy Modalities; Proprioception; Randomized Controlled Trials as Topic; Tai Ji; Treatment Outcome
PubMed: 35395764
DOI: 10.1186/s12891-022-05278-w -
International Endodontic Journal Apr 2022Consensus on the treatment of choice for complicated crown fractures of teeth is limited. Recent guidance recommends vital-pulp-therapy; however, the preferred type is... (Review)
Review
BACKGROUND
Consensus on the treatment of choice for complicated crown fractures of teeth is limited. Recent guidance recommends vital-pulp-therapy; however, the preferred type is not specified. Higher success rates for pulpotomy compared to pulp-capping have been documented, which suggests pulpotomy may be a preferable option for complicated crown-fractures.
OBJECTIVES
The purpose of this systematic review was to determine the success rate of pulpotomy (partial and complete) on teeth that suffered complicated crown fractures.
PARTICIPANTS
patients who have suffered a complicated crown fracture to an anterior permanent tooth.
INTERVENTION
pulpotomy (partial or complete). Comparator: pulp-capping or root canal treatment.
OUTCOME
combined clinical and radiographic success at or after 12 months.
METHODS
A systematic literature using key search terms was conducted using PubMed, Web of Science and Cochrane-Central-Register-of-Controlled-Trials (CENTRAL) as well as a grey literature search from inception to May 2021 and without language restricted to English. Strict inclusion criteria were applied. A standardized tool with defined criteria to assess the risk of bias in each study was used. For non-randomized comparative trials, the Robins-I tool was used while the Newcastle-Ottawa scale was used for non-comparative non-randomized studies.
RESULTS
Seven retrospective clinical studies were included. The studies reported high success rates for pulpotomy with overall success ranges for partial or complete pulpotomy ranging from 75% to 96%. One study compared the success rates of pulpotomy to an alternative treatment option pulp capping (90.9% vs. 67%, respectively). Due to the lack of homogeneity in the included studies, a meta-analysis was not possible.
DISCUSSION
This review highlights the limited evidence based for the current guidance on treatment of complicated crown fractures. The findings of the review indicate high success rates for pulpotomy; however, there is a moderate risk of bias and small sample sizes in the included studies with the result that the overall results should be interpreted with caution.
CONCLUSION
Within the limitations of this review, the benefits and high success rates reported for partial pulpotomy suggest this procedure, rather than pulp-capping, should be considered as the treatment of choice for both immature and mature teeth that have suffered complicated crown-fractures.
Topics: Crowns; Dental Pulp Capping; Dentition, Permanent; Humans; Pulpotomy; Retrospective Studies; Treatment Outcome
PubMed: 35076954
DOI: 10.1111/iej.13690 -
International Journal of Implant... Nov 2021Implant-assisted removable partial dentures (IARPDs) have recently become popular, but little information is available on the treatment outcomes based on the Kennedy... (Review)
Review
BACKGROUND
Implant-assisted removable partial dentures (IARPDs) have recently become popular, but little information is available on the treatment outcomes based on the Kennedy classification and attachment types.
OBJECTIVE
The objective of this review was to evaluate the treatment outcomes of IARPD delivered for distal extension edentulous areas based on the differences in the Kennedy classification and attachment type.
MATERIALS AND METHODS
English-language clinical studies on IARPD published between January 1980 and February 2020 were collected from MEDLINE (via PubMed), the Cochrane Library (via the Cochrane Central Register of Controlled Trials), Scopus online database, and manual searching. Two reviewers selected the articles based on pre-determined inclusion and exclusion criteria, followed by data extraction and analysis.
RESULTS
Eighty-one studies were selected after evaluating the titles and abstracts of 2410 papers. Nineteen studies were finally included after the perusal of the full text. Fourteen studies focused on Class I, 4 studies investigated both Class I and II, and only 1 study was conducted on Kennedy's class II. Eight types of attachments were reported. The ball attachment was the most frequently used attachment, which was employed in 8 of the included studies. The implant survival rate ranged from 91 to 100%. The reported marginal bone loss ranged from 0.3 mm to 2.30 mm. The patient satisfaction was higher with IARPD than with conventional RPDs or that before treatment. The results of prosthetic complications were heterogeneous and inconclusive.
CONCLUSION
IARPD exhibited favorable clinical outcomes when used as a replacement for distal extension edentulous areas. The comparison between the clinical outcomes of Kennedy's class I and II was inconclusive owing to the lack of studies focusing on Kennedy Class II alone. The stud attachment was the most commonly used type in IARPDs. Overall, the different attachment systems did not influence the implant survival rate and patient satisfaction. Further high-quality studies are needed to investigate the attachment systems used in IARPD.
Topics: Dental Implants; Dental Prosthesis, Implant-Supported; Denture, Partial, Removable; Humans; Patient Satisfaction; Treatment Outcome
PubMed: 34773513
DOI: 10.1186/s40729-021-00394-z -
Scandinavian Journal of Medicine &... Oct 2021Nowadays, there is a lack of consensus and high controversy about the most effective range of motion (ROM) to minimize the risk of injury and maximize the resistance... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Nowadays, there is a lack of consensus and high controversy about the most effective range of motion (ROM) to minimize the risk of injury and maximize the resistance training adaptations.
OBJECTIVE
To conduct a systematic review and meta-analysis of the scientific evidence examining the effects of full and partial ROM resistance training interventions on neuromuscular, functional, and structural adaptations.
METHODS
The original protocol (CRD42020160976) was prospectively registered in the PROSPERO database. Medline, Scopus, and Web of Science databases were searched to identify relevant articles from the earliest record up to and including March 2021. The RoB 2 and GRADE tools were used to judge the level of bias and quality of evidence. Meta-analyses were performed using robust variance estimation with small-sample corrections.
RESULTS
Sixteen studies were finally included in the systematic review and meta-analyses. Full ROM training produced significantly greater adaptations than partial ROM on muscle strength (ES = 0.56, p = 0.004) and lower-limb hypertrophy (ES = 0.88, p = 0.027). Furthermore, although not statistically significant, changes in functional performance were maximized by the full ROM training (ES = 0.44, p = 0.186). Finally, no significant superiority of either ROM was found to produce changes in muscle thickness, pennation angle, and fascicle length (ES = 0.28, p = 0.226).
CONCLUSION
Full ROM resistance training is more effective than partial ROM to maximize muscle strength and lower-limb muscle hypertrophy. Likewise, functional performance appears to be favored by the use of full ROM exercises. On the contrary, there are no large differences between the full and partial ROM interventions to generate changes in muscle architecture.
Topics: Adaptation, Physiological; Humans; Muscle Strength; Range of Motion, Articular; Resistance Training
PubMed: 34170576
DOI: 10.1111/sms.14006 -
The Cochrane Database of Systematic... Feb 2022Focal segmental glomerulosclerosis (FSGS) can be separated into primary, genetic or secondary causes. Primary disease results in nephrotic syndrome while genetic and... (Review)
Review
BACKGROUND
Focal segmental glomerulosclerosis (FSGS) can be separated into primary, genetic or secondary causes. Primary disease results in nephrotic syndrome while genetic and secondary forms may be associated with asymptomatic proteinuria or with nephrotic syndrome. Overall only about 20% of patients with FSGS experience a partial or complete remission of nephrotic syndrome with treatment. FSGS progresses to kidney failure in about half of the cases. This is an update of a review first published in 2008.
OBJECTIVES
To assess the benefits and harms of immunosuppressive and non-immunosuppressive treatment regimens in adults with FSGS.
SEARCH METHODS
We searched the Cochrane Kidney and Transplant Register of Studies to 21 June 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.
SELECTION CRITERIA
Randomised controlled trials (RCTs) and quasi-RCTs of any intervention for FSGS in adults were included. Studies comparing different types, routes, frequencies, and duration of immunosuppressive agents and non-immunosuppressive agents were assessed.
DATA COLLECTION AND ANALYSIS
At least two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random-effects model and results were expressed as a risk ratio (RR) for dichotomous outcomes, or mean difference (MD) for continuous data with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
MAIN RESULTS
Fifteen studies (560 participants) were included. No studies specifically evaluating corticosteroids compared with placebo or supportive therapy were identified. Studies evaluated participants with steroid-resistant FSGS. Five studies (240 participants) compared cyclosporin with or without prednisone with different comparators (no specific treatment, prednisone, methylprednisolone, mycophenolate mofetil (MMF), dexamethasone). Three small studies compared monoclonal antibodies (adalimumab, fresolimumab) with other agents or placebo. Six single small studies compared rituximab with tacrolimus, cyclosporin plus valsartan with cyclosporin alone, MMF with prednisone, chlorambucil plus methylprednisolone and prednisone with no specific treatment, different regimens of dexamethasone and CCX140-B (an antagonist of the chemokine receptor CCR2) with placebo. The final study (109 participants) compared sparsentan, a dual inhibitor of endothelin Type A receptor and of the angiotensin II Type 1 receptor, with irbesartan. In the risk of bias assessment, seven and five studies were at low risk of bias for sequence generation and allocation concealment, respectively. Four studies were at low risk of performance bias and 14 studies were at low risk of detection bias. Thirteen, six and five studies were at low risk of attrition bias, reporting bias and other bias, respectively. Of five studies evaluating cyclosporin, four could be included in our meta-analyses (231 participants). Cyclosporin with or without prednisone compared with different comparators may increase the likelihood of complete remission (RR 2.31, 95% CI 1.13 to 4.73; I² = 1%; low certainty evidence) and of complete or partial remission (RR 1.64, 95% CI 1.10 to 2.44; I² = 19%) but not of partial remission (RR 1.36, 95% CI 0.78 to 2.39, I² = 22%). In Individual studies, cyclosporin with prednisone versus prednisone may increase the likelihood of partial (49 participants: RR 7.96, 95% CI 1.09 to 58.15) or complete or partial remission (49 participants: RR 8.85, 95% CI 1.22 to 63.92) but not of complete remission. The remaining individual comparisons may make little or no difference to the likelihood of complete remission, partial remission or complete or partial remission compared with no treatment, methylprednisolone, MMF, or dexamethasone. Individual study data and combined data showed that cyclosporin may make little or no difference to the outcomes of chronic kidney disease or kidney failure. It is uncertain whether cyclosporin compared with these comparators in individual or combined analyses makes any difference to the outcomes of hypertension or infection. MMF compared with prednisone may make little or no difference to the likelihood of complete remission (33 participants: RR 1.05, 95% CI 0.58 to 1.88; low certainty evidence), partial remission, complete or partial remission, glomerular filtration rate, or infection. It is uncertain whether other interventions make any difference to outcomes as the certainty of the evidence is very low. It is uncertain whether sparsentan reduces proteinuria to a greater extent than irbesartan.
AUTHORS' CONCLUSIONS
No RCTs, which evaluated corticosteroids, were identified although the KDIGO guidelines recommend corticosteroids as the first treatment for adults with FSGS. The studies identified included participants with steroid-resistant FSGS. Treatment with cyclosporin for at least six months was more likely to achieve complete remission of proteinuria compared with other treatments but there was considerable imprecision due to few studies and small participant numbers. In future studies of existing or new interventions, the investigators must clearly define the populations included in the study to provide appropriate recommendations for patients with primary, genetic or secondary FSGS.
Topics: Adult; Cyclosporine; Glomerulosclerosis, Focal Segmental; Humans; Immunosuppressive Agents; Mycophenolic Acid; Prednisone; Randomized Controlled Trials as Topic
PubMed: 35224732
DOI: 10.1002/14651858.CD003233.pub3