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BMJ 2012;344:e3533 doi: 10.1136/bmj.

e3533 (Published 13 June 2012) Page 1 of 11

Research

RESEARCH

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

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Meg J Jardine senior research fellow and staff specialist (nephrology) , Amy Kang honours student
13 14
and resident medical officer , Sophia Zoungas professorial fellow and associate professor ,
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Sankar D Navaneethan assistant professor , Toshiharu Ninomiya assistant professor , Sagar U
7 12
Nigwekar clinical and research fellow , Martin P Gallagher head of renal policy , Alan Cass senior
1 89
director , Giovanni Strippoli adjunct associate professor and renal research coordinator , Vlado
1
Perkovic acting executive director
1
George Institute for Global Health, PO Box M201, Camperdown, NSW 2050, Australia; 2Concord Repatriation General Hospital, Sydney, Australia;
3
Royal North Shore Hospital, Sydney; 4School of Public Health, Monash University, Melbourne, Australia; 5Department of Nephrology and Hypertension,
Cleveland Clinic, Cleveland, OH, USA; 6Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University,
Fukuoka, Japan; 7Massachusetts General Hospital, Boston, MA, USA; 8School of Public Health, University of Sydney; 9Mario Negri Sud Consortium,
Italy

Abstract Results 11 trials were identified that reported on 4389 people with
Objective To systematically review the effect of folic acid based chronic kidney disease, 2452 with end stage kidney disease, and 4110
homocysteine lowering on cardiovascular outcomes in people with kidney with functioning kidney transplants (10 951 participants in total). Folic
disease. 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
Design Systematic review and meta-analysis.
any of the secondary outcomes. There was no evidence of heterogeneity
Data sources Medline, Embase, the Cochrane Library, and in subgroup analyses, including those of kidney disease category,
ClinicalTrials.gov to June 2011. background fortification, rates of pre-existing disease, or baseline
Study selection Randomised trials in people with non-dialysis dependent homocysteine level. The definitions of chronic kidney disease varied
chronic kidney disease or end stage kidney disease or with a functioning widely between the studies. Non-cardiovascular events could not be
kidney transplant reporting at least 100 patient years of follow-up and analysed as few studies reported these outcomes.
assessing the effect of folic acid based homocysteine lowering therapy. Conclusions Folic acid based homocysteine lowering does not reduce
No language restrictions were applied. cardiovascular events in people with kidney disease. Folic acid based
Data extraction Two reviewers independently extracted data on study regimens should not be used for the prevention of cardiovascular events
setting, design, and outcomes using a standardised form. The primary in people with kidney disease.
endpoint was cardiovascular events (myocardial infarction, stroke, and
cardiovascular mortality, or as defined by study author). Secondary Introduction
endpoints included the individual composite components, all cause
People with kidney disease of any severity experience excess
mortality, access thrombosis, requirement for renal replacement therapy,
cardiovascular events and mortality compared with the general
and reported adverse events, including haematological and neurological
population. High plasma homocysteine levels increase as
events. The effect of folic acid based homocysteine lowering on outcomes
estimated glomerular filtration rate levels decline with the
was assessed with meta-analysis using random effects models.
prevalence of hyperhomocysteinaemia (defined in relation to
the upper limit of the reference range), reported to be 36-89%

Correspondence to: M J Jardine mjardine@georgeinstitute.org.au
Extra material supplied by the author (see http://www.bmj.com/content/344/bmj.e3533?tab=related#webextra)
Search strategy
Supplementary table and figures

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all spellings of homocysteine. and included in people with cardiovascular disease or diabetes (mean 13 cardiovascular events (defined as myocardial infarction. stroke. study intervention (folic acid alone versus folic acid extracted data. baseline homocysteine level (more or No commercial reuse: See rights and reprints http://www. Embase (1966 to June 2011).bmj. cardiovascular disease. We considered studies to be eligible if led to the hypothesis that reducing homocysteine levels could they compared folic acid based homocysteine lowering therapy reduce the burden of cardiovascular disease. or as defined by study authors.gov website for additional studies. AK) independently searched the literature.BMJ 2012. We searched Medline via Ovid (1950 to June plots of the natural log of the relative risk versus its standard 2011).20 Data extraction and quality assessment That study utilised serum creatinine levels rather than an Using a standardised form two reviewers (MJJ.4 5 and from the corresponding author). 80-94.13 filtration rate of 15-59 mL/min/1. stroke. where therapy prevents requirement for dialysis. dermatological. intervention characteristics. mean duration of the effects of folic acid based homocysteine lowering compared follow-up. The I2 statistic was used to estimate the percentage of variability When necessary we contacted authors or principal investigators across studies attributable to heterogeneity beyond chance. defined as previous myocardial infarction or as µmol/L). and kidney Data synthesis and analysis transplantation (see supplementary file for search strategy). which is noticeably in situ with no requirement for maintenance dialysis. vitamin B. and malignant events. studies with placebo or usual care or if they compared a higher dose of of homocysteine lowering in the general population have failed folic acid based homocysteine lowering therapy with a lower to show clear cardiovascular benefits. Methods completeness of study and follow-up. and ≥95 cardiac disease.6-10 High all completed randomised controlled trials assessing the effects homocysteine levels have been associated with an increased of folic acid based homocysteine lowering therapy on risk of cardiovascular events11 in the general population.bmj.1-3 standardised approach and a prespecified protocol (available 70-75% in those with functioning kidney transplants. Studies with a sequential or crossover cardiovascular events observed in the general population has design were excluded.17 A key distinction between the two functioning kidney transplant was defined as a kidney transplant populations is the level of homocysteine. Subgroup heterogeneity was estimated by the Cochran C test. cardiovascular disease lie between those of the general population and those mortality.e3533 (Published 13 June 2012) Page 2 of 11 RESEARCH in patients with chronic kidney disease depending on severity. myocardial infarction. or as defined by study authors. one study dose. renal dialysis.344:e3533 doi: 10.73 m2.1136/bmj. Homocysteine levels in people with kidney and cardiovascular death).13-16 Moreover. and has driven the conduct of randomised trials in this patient neurological.22 therefore we used the intention to treat data in these stage kidney disease. A cardiovascular events. Analyses were done To identify any other relevant studies we manually scanned the with the metan command using reported raw event counts where reference lists of identified trials and review articles and possible. including gastrointestinal.23 Potential small study bias was assessed with the to PRISMA21guidelines for the conduct of meta-analyses of Harbord test24 and represented graphically with Begg funnel intervention trials. dialysis with classic homocysteinuria. study population. disease. and assessed the quality of trials using a plus B group vitamins). group.25 Disagreements on abstracted data were resolved by database (Cochrane central register of controlled trials). baseline We undertook a systematic review and meta-analysis to examine and achieved mean homocysteine levels.com/permissions Subscribe: http://www. presence of diabetes. and the Cochrane Library error. an estimated glomerular B6. and compared the impact of relatively mild differences in renal severity of kidney disease. Study selection Prespecified subgroup analyses included classification of kidney Two reviewers (MJJ. Data were extracted with placebo or control treatments on cardiovascular events and according to intention to treat principles. One study in people other clinical outcomes in people with a range of severity of with functioning renal transplants reported both intention to kidney disease. and the start of renal replacement therapy that homocysteine lowering may be useful in people with kidney among participants not requiring dialysis. or otherwise using reported relative risk estimates. and intention to treat A systematic review of the literature was carried out according analysis. care providers. µmol/L13 14 18). risk ratios using a random effects model. blinding of outcome assessors. and vitamin kidney disease stage 3-4 (that is. the seen in people with homocysteinuria. with cardiovascular outcomes in people with kidney disease a 25% lower homocysteine level associated with an 11% lower (including those receiving maintenance dialysis or with a risk of coronary artery disease and a 19% lower risk of stroke. defined by study authors). using consensus and involvement of a third reviewer (VP) when relevant text words and medical subject headings that included necessary. vitamin B12. leg amputation. or history of function (serum creatinine concentrations <80. Chronic kidney disease was defined as the National Kidney in people with a history of myocardial infarction suggested harm Foundation kidney disease outcomes quality initiative chronic with use of a combination of folic acid.73 m2). kidney disease. and participants.12 functioning kidney transplant) and with a minimum of 100 The direct relation between homocysteine levels and patient years of follow-up.19 This has led to the hypothesis access thrombosis. The higher (100-400 µmol/L) in people with homocysteinuria than outcomes assessed were prespecified. all cause mortality. End stage kidney disease was defined as an estimated The lack of benefit in the general population contrasts with that glomerular filtration rate of less than 15 mL/min/1. with studies weighted using the inverse variance method.com/subscribe . The We obtained summary estimates of overall and subgroup relative search was limited to randomised clinical trials in any language. A meta-analysis of eight large trials using individual patient level data found the lack of effect of homocysteine lowering to be consistent across categories of renal function. sex. despite the lack of benefit in the broader population. The quality of the study report was determined by assessing concealment of treatment allocation. including kidney transplant recipients and those treat analyses and analyses censored for loss of transplant with non-dialysis dependent chronic kidney disease and end function. analyses.26 for original data. and numbers of outcome events. However. were collected. We considered for inclusion 85-100% in those with end stage kidney disease. searched the clinicaltrials. Data on adverse events disease. folic acid. AK) extracted estimate of glomerular filtration rate to assess renal function data on participant characteristics (age.

with no heterogeneity overall or greater than 120 µmol/L. ranged from 50% to 98% (median 64%). or µmol/L.e3533 (Published 13 June 2012) Page 3 of 11 RESEARCH less than 20 µmol/L. P=0.22 30 these outcomes. dermatological.08. 1. Follow-up ranged from 24 to 60 figure 9). and composite definition (the Baseline mean homocysteine levels ranged from 15.bmj. proportion of study participants with mg) dose daily oral folic acid supplementation.05 as significant for all of grain with folic acid. 95% confidence interval 0.33 Some trials reported only calculation.326). The mean between studies.5 and 72. of the current analysis the high and medium dose arms were proportion of study participants with cardiac disease at baseline combined and compared with the low dose arm. relative with placebo or comparing different dose intensities.97 µmol/L (95% confidence interval −9.03. (Stata. Tolerability of homocysteine lowering agents and the proportion with a history of cardiac disease ranged from Adverse event rates were reported by seven trials (supplementary 11% to 100% (median 34%). myocardial infarction (eight trials.com/subscribe .00.8 Trial participants P=0.11. 0.11. 95% confidence interval 0.96.2 kidney transplant (one study. supplementary figure 3).8 9 22 30 33 Homocysteine levels were reduced into the malignancies. TX. 95% disease. rates (relative risk 1. both of which analyses of gastrointestinal. The rates of reported adverse events varied noticeably were reduced by folic acid based therapy (table).8% (adverse events leading to difference in homocysteine levels between treated and control withdrawal from study treatment)6 to 89.9 to 22. Baseline homocysteine levels were increased at baseline and P=0. and low (1 background fortification.02 0.7 8 and people with a functioning kidney mortality (six trials.32 One trial was carried out in people between different categories of kidney disease.96.34 risk 1. with diabetic nephropathy.5 mg and 40 mg Subgroup analyses (table). study event number (more or less than the the intention to treat analyses were selected for our review. the approximate 95th centile for with low dose vitamins (table). and were carried out in populations with milder degrees of renal malignant events owing to the small number of trials reporting dysfunction.92 to 1. and three compared an intervention No commercial reuse: See rights and reprints http://www. One trial that (more or less than the approximate median). data provided by the authors for one study. 150 events).16) or a functioning The mean age of trial participants was between 48. 5968 participants. homocysteine two different methods of homocysteine lowering therapy (50 lowering therapy did not reduce rates for start of renal mg intravenous 5-methyltetrahydrofolate three times a week replacement therapy in people with non-dialysis dependent compared with 5 mg oral folic acid daily) rather than comparing chronic kidney disease (two studies. diabetes. approximate median. whereas one was done with partial analyses. way comparison of high (15 mg).75 to 1.bmj. supplementary figure 7). defined as the coexistence of diabetes Homocysteine lowering did not affect rates of access thrombosis and albuminuria (minimum 300 mg/day) or proteinuria (three trials. 2452 with end stage kidney overall effect on cardiovascular events (relative risk 0. one compared an intervention subgroups studied (fig 3⇓). disease was defined as an estimated glomerular filtration rate or stroke (eight trials. such as dizziness. 0. 1.22 Three papers reported on subgroups of confidence interval 0. confidence interval 0. Statistical analyses were carried out with Stata 11. of which 36 were reviewed in full text (fig 1⇓). 9852 participants). USA).6 to 47 prespecified definition of myocardial infarction.1136/bmj. both analyses on outcomes censored three months after the start average follow-up time (more or less than the approximate of dialysis and outcomes of intention to treat analyses. to −0. The proportion of trial participants who were male 1. totalling 4389 with participants (fig 2⇓).83 to (minimum 500 mg/day).84 to 1.21.92 to 1.97.467 for heterogeneity). group. Patient characteristics examined with usual care (no placebo).44 including “many transient minor complaints.16. of stroke or transient ischaemic attack.com/permissions Subscribe: http://www.344:e3533 doi: 10.37.33 One trial was excluded as it compared 1. Homocysteine lowering therapy had no stage 3-4 chronic kidney disease. 4110 participants. ranging from 1.22 of which median.30 survivors of myocardial infarction. Eleven randomised trials provided information Ten studies reported 3045 cardiovascular events among 10 863 on 10 951 participants with kidney disease.97. 0. 8586 participants. relative risk 0. Seven trials compared cardiovascular events did not differ significantly in any of the an intervention with placebo. There was no Trials were reported between 2004 and 2011. The interventions were predominantly based on daily oral folic acid supplementation in doses of between 2. 95% confidence interval 0. One trial consisted of a three homocysteine in men and women in the United States27).6 9 28 29 both end stage kidney disease and chronic outcomes.0 fortification of grain.91 to years (table). 30 months). 95% transplant in one trial. 8772 participants.32 where chronic kidney 8586 participants.9 30 We were unable to complete planned separate normal range (≤12 µmol/L) in only two studies. 1543 participants. Homocysteine lowering did not affect cardiovascular disease in two trials. stroke. or other definition according to the study which ranged from 11. relative risk 0. supplementary figure 5). Effect of homocysteine lowering therapy on Results outcomes Cardiovascular events The search yielded 359 articles.0%. of less than 60 ml/min30 31 or a serum creatinine concentration supplementary figure 6). with additional evidence of heterogeneity across the included studies (I2=0. 0. all chronic kidney disease from larger trials of vascular disease or cause mortality (nine trials. consisted entirely of people with end stage kidney disease for Supplementary figure 2 shows the effects on secondary four trials.93). and 4110 with functioning kidney transplants (table⇓).95. supplementary figure 8). whether the overall recruited people with a functioning kidney transplant reported study population was recruited on the basis of kidney disease. Five trials reported achieved mean homocysteine levels.82 to 1. cardiovascular death.31 and survivors supplementary figure 4). medium (5 mg). 0. Homocysteine lowering had no effect on adverse event months (median 38 months. In addition. the proportion with a diagnosis of diabetes ranged from 11% to 100% (median 40%). Four trials were done on a background of fortification We considered a P value of less than 0. Cointerventions included supplementation with B group The impact of folic acid based homocysteine lowering on vitamins (seven trials.12.BMJ 2012. neurological.10.05.49) in the five studies reporting the requisite data for the nausea or headache”). table).95 to 1.6 µmol/L in the intervention authors).95 to 1.6 For the purposes diabetes at baseline (more or less than the approximate median).1% (adverse events participants was −4.

coronary heart disease.32 The addition of the VITATOPS results to those of composite endpoint (P=0. There was no evidence of heterogeneity in subgroup that none of these factors had a significant impact on the overall analyses comparing the impact of the intervention according to meta-analysis (results not shown). representing 12% of the individual patient Trials were overall of high quality (supplementary table 1) with data meta-analysis and 40% of the current report. the VITATOPS trial carried out in people with (primary chronic kidney disease versus subgroup of larger study: recent stroke or transient ischaemic attack found no significant P=0.00. a population in whom drug burden is often high.15 The possibility of benefit for stroke outcomes for heterogeneity). In 2006. with the point estimate favouring the the trials. 0. P=0.344:e3533 doi: 10. There events (seven trials. average follow-up time.bmj.com/subscribe .346 for cardiovascular disease. stroke. and the proportion with cardiac disease (P=0. chronic kidney disease. Participants. the proportion with diabetes (P=0. randomisation to folic acid kidney disease based homocysteine lowering therapy did not affect the A previous systematic review of folic acid based homocysteine incidence of cardiovascular events. 80-94.68 to 1. stroke. These outcomes were consistent across categories of intervention but with some imprecision.568 for heterogeneity). myocardial infarction. the number of events in the study (P=0.e3533 (Published 13 June 2012) Page 4 of 11 RESEARCH included kidney disease classification (P=0.76 to 0.81 heterogeneity).637 confidence interval 0.94. or myocardial infarction. study staff.009) and no significant people with kidney disease. These data are consistent with studies in the general population. The effect of previous studies again found no reduction in cardiovascular any exposure to folic acid in the controls was assessed through events. stroke. Continuous variables vitamins or to control for the prevention of vascular disease. 95% confidence interval 0.342 effect on cardiovascular events (relative risk 0.36 37 Our findings suggest that folic acid based lowering to comprehensively summate the available evidence.20 (baseline homocysteine levels. permitting a broader recommend supplementation of folic acid and B group vitamins study population.741 cause mortality.01).1136/bmj. There was low risk of bias as a result of former report (1987 participants). Many people with kidney disease seem to be with 3886 in seven trials in the previous analysis) through the receiving folic acid supplementation35 and some guidelines inclusion of all kidney disease categories. lowering in people with advanced or end stage kidney disease cardiovascular mortality.bmj.204 for heterogeneity). 3619 participants. 3886 participants. 95% for heterogeneity). with no evidence of participants in the current review (10 951 in 11 trials compared heterogeneity. The previous meta-analysis summated the separate reports for various cardiovascular outcomes (for example. review adds to this evidence by similarly excluding meaningful benefit in kidney disease.75 variation in definitions and rates of adverse events reported in to 1.00.121 for heterogeneity) and through any exposure either B-Vitamin Treatment Trialists’ Collaboration in 2010 of 37 485 by background fortification or by trial administered low dose participants in eight trials randomised to folate containing B folic acid (P=0. a meta-analysis heterogeneity). with results confirming levels.815 for heterogeneity). P=0.06). all cause mortality. although this conclusion should reduction in a composite of myocardial infarctions. or all heterogeneity).877 for heterogeneity). Trial characteristics studied included the was raised in 2007 in a meta-analysis of eight trials (relative intervention (use of folic acid compared with folic acid plus B risk 0. trial proportion with diabetes. 0. mortality.85. Discussion Comparison with previous systematic reviews In this large systematic review including over 10 000 of homocysteine-lowering in people with participants with kidney disease. Evidence of small study publication bias was lacking lowering therapy in the general population. stroke (0.38 group vitamins: P=0. 95% was no evidence of harm.92. no impact on major vascular events.06). Our study included all reports of outcomes or of water soluble vitamins in people with kidney disease on for patients with kidney disease randomised to homocysteine prudential grounds.96. The meta-analysis showed that folic acid supplementation had trial proportion with cardiac disease. and perhaps be interpreted with caution given the noticeable cardiovascular death (five trials. found to prevent cardiovascular events in large randomised In our analysis we elected to use the trial definition where this trials.91. P=0. the type of study More recently. and outcome assessors were studies that did not meet the 1000 participant criteria of the blinded in 10 studies. reported a reduction in all fatal and non-fatal cardiovascular requirement for dialysis treatment.86 to 1. P=0.368 for of 12 randomised trials reported no effect on the risk of heterogeneity). serum creatinine concentrations (<80. baseline homocysteine levels (P=0. 0. 0.05) or stroke (0.82 to 1.00. myocardial Comparison with systematic reviews of infarction. and ≥95 µmol/l). or access thrombosis. or death from cardiovascular cause resulting in the potential for where folic acid based homocysteine lowering has also not been some participants to contribute to the outcome more than once. stroke.BMJ 2012. The different approach to folic acid based homocysteine lowering in the general population the treatment of the composite accounts for most of the No commercial reuse: See rights and reprints http://www.39 Differences between kidney disease (end stage kidney disease.045). sudden cardiac death) to derive a figure for homocysteine lowering in all populations a composite of non-fatal myocardial infarction. Previous systematic reviews have analysed the effect of study’s composite was not reported. the analyses include the near threefold higher number of and functioning kidney transplant). homocysteine lowering therapy should not be used for the permitting the inclusion of the post hoc analysis of HOPE-2. and the use of a predefined cardiovascular to 1.785 for as successive trials have been reported.30 prevention of cardiovascular events in people with kidney Additionally the two studies had methodological differences.82. non-fatal stroke. and the current (Harbord test P=0.850). The trialists’ analysis included 4361 participants contained in Quality the current analysis. The additional the method of sequence generation clear in eight of the 11 6590 participants included in the current report are from studies studies and explicit details of allocation concealment in 10 published after the previous report (4603 participants) or from studies.87.32 background folic acid fortification in the studied population An individual patient meta-analysis was published by the (P=0. the average follow-up time (P=0. relative risk 0. These studies have effectively outcome reporting and selective outcome reporting in all 11 excluded any beneficial cardiovascular effect of homocysteine trials. disease. or cancer and number of events in the study) were also explored using incidence despite an average 25% reduction in homocysteine metaregression in sensitivity analyses.com/permissions Subscribe: http://www. defined by rates of adverse events in confidence interval 0.

40 The addition of disease around the world. earlier reports of clear relations between homocysteine levels and cardiovascular We thank SZ and K Polkinghorne for additional data from the ASFAST events in people with kidney disease43 have been challenged by study.762 to 1.81 to 1.com/subscribe .015) in the four studies where both methods found that folic acid based therapy had no impact on major can be tested. MJJ inverse association.91 (95% authors had full access to all of the data (including statistical reports confidence interval 0.8 mg being these are reported.344:e3533 doi: 10. with the risk The difference was not significant (P=0. Limitations include the reliance on folic acid or higher. AK contributed to the study design. administered. contributed to the study design and revised the paper. which increased by 9% with every 5 µmol/L increase Heart Foundation of Australia Career Development Award. poor nutrition and inflammatory state common in patients Contributors: MJJ contributed to the study design. The authors were independently generation of the “reverse epidemiology hypothesis. Impact of background fortification on GS contributed to the study design and revised the paper. Further 1. Some or less in treated participants in all but two studies. folic acid based homocysteine lowering does not Observed relation of homocysteine levels with prevent cardiovascular events in people with kidney disease and cardiovascular events in people with kidney consideration should be given to discontinuing its use for disease cardiovascular prevention in this population. We could only include results homocysteine levels were largely not normalised despite doses for people with kidney disease included in larger trials where of folic acid substantially greater than 0.46 47 Another explanation the paper. a finding that has been shown previously. either through fortification or through comparator treatment. In 25 trials of homocysteine lowering utilising 0.880 (0.02) in trials where controls had no and tables) in the study and can take responsibility for the integrity of exposure to folic acid based regimens. individual patient level data analysis of participants in all completed trials through the conduct of further analyses using homocysteine lowering trials according to kidney disease status data at individual patient level. a Banyu Life Science Foundation International fellowship programme whereas prospective studies showed no association with all (Japan) and by a Foundation of High Blood Pressure Research ISH cause mortality but a positive association with cardiovascular visiting postdoctoral award (Australia). to impaired folic acid metabolism and impaired folate absorption as well as impaired renal clearance.bmj. Regardless study design. SDN contributed to the study design and revised the paper. and the maximal homocysteine lowering of a standardised 23% clear result. All The relative risk of cardiovascular events was 0. is that articles.10 A meta-analysis of observational studies and MPG were supported by grants from the Royal Australasian College in end stage kidney disease found no association between of Physicians Jacquot Research Establishment. No commercial reuse: See rights and reprints http://www. the importance of the clinical question. performed statistical analyses and in people with kidney disease do not lead to a reduction in revised the paper.06) in trials where controls did have some level of exposure. and revised the paper. screened supported by some45 48 49 but not all5 50 51 analyses. Impact of folic acid on homocysteine lowering Strengths and limitations of the review in people with and without kidney disease The strengths of this systematic review are its rigorous Doses of 0. These observations of the risks supported by a NSW Cardiovascular Research Network Heart associated with various homocysteine levels led in part to the Foundation of Australia fellowship. ratio falling from 0. and one of studies used different definitions for the primary outcome of these was carried out in participants with kidney disease. extracted data cardiovascular events. although this did not seem to Conversely among the trials of the current analysis.20 Short of further randomised information and precision could be gained from analysis of all trials. extracted data and revised the paper. VP initated homocysteine lowering the study. may increase analysis power providing greater clarity. to 1. SZ contributed to the homocysteine is simply a marker of kidney function. AC contributed to the study design and revised the paper. SUN contributed to the study design. screened articles.047) The individual patient data meta-analysis of eight large trials to 0.8 mg folic acid supplements. whether administered against a background of likely to be a better estimate of the true effect of folic acid based fortification (relative risk 0. many of whom are currently taking 30%.41 42 It However this would be expected to exaggerate any benefit and has been postulated that the relative resistance of patients with none was found. analysis. homocysteine was lowered to 12 µmol/L tabular data rather than individual patient level data.09) or not (1. We believe the findings of the current review are vascular events. MPG contributed to the study design and revised the paper. SZ was supported by a National events. interpretation. TN was supported by homocysteine levels and clinical events in retrospective studies. Funding: This study received no external funding. including millions receiving dialysis vitamin B12 increased the degree of homocysteine lowering to for end stage kidney disease. obtained data from one of the trials.1136/bmj.” which responsible for the study design.09). Furthermore. of the nature of the association reported by observational studies. The findings have direct implications for the reduction in trials of participants where folic acid dose was management of hundreds of millions of people with kidney compared with homocysteine reduction.41 cardiovascular events. preparation asserts altered risk factor patterns may be confounded by the of the manuscript. compared with 0.com/permissions Subscribe: http://www.BMJ 2012. requiring dialysis such that the association of homocysteine and extracted data.96 to 1.99 (0.902 to 1. for assistance with the search strategy and implementation. VP was in homocysteine levels.02.972 (95% confidence interval 0. 0. and revised the paper. meaningfully impact the findings. sourced articles.43 Conclusion In summary. trials search coordinator of the Cochrane Renal more recent studies observing no association44 45 or even an Group.90 to homocysteine lowering on cardiovascular outcomes. raising the possibility of reporting bias.bmj. Adding further strength to these conclusions.93 the data and the accuracy of the data analysis. performed statistical analyses and drafted and revised outcomes is driven by nutritional state.24 for heterogeneity). Gail Higgins. the definition of chronic kidney end stage kidney disease to folic acid based therapy may be due disease varied among the studies (see table). and the decision to submit for publication.99 99% confidence interval 0. TN it is now clear that interventions to lower homocysteine levels contributed to the study design.8 mg of folic acid or more are required to achieve methodology.e3533 (Published 13 June 2012) Page 5 of 11 RESEARCH difference between ours and the previous report.

Matsuo T. Humphreys MH. et al. Westphal SMD. of homocysteine lowering on mortality and vascular disease in advanced chronic kidney double-blind. Guarino PD. Fasting plasma total homocysteine levels and mortality and allograft loss in kidney 30 Mann JFE. 37 Holt S. Wu V-C. and 21 Moher D. Homocysteine-lowering vitamin B treatment 35 Andreucci VE. randomized controlled trial.11:134-7.25:3443-57. Lewington S. which companies might have an interest in the submitted work recipients: primary results from the folic acid for vascular outcome reduction in in the previous three years.renal. Kusek JW. Circulation 2011. et al. with folic acid and B vitamins in vascular disease. Selhub J. inflammation in ESRD patients.15:442-53. B 2006. JAMA Randomized trial of folic acid for prevention of cardiovascular events in end-stage renal 2010. SZ is a member of the myocardial infarction.9:855-65. Nephrol Dial Transplant 2008.aspx# and stroke: a meta-analysis. parallel.170:1622-31.64:208-15. Chiarello PG. AMGEN.BMJ 2012. placebo-controlled trial. Lin Y-L. A low. Milani S. hyperhomocysteinemia: a randomized trial of folate treatment for the prevention of 4 Winkelmayer WC. graphical test. vitamins and the risk of total mortality and cardiovascular disease in end-stage renal 3 Menon V.288:2015-22. Effects of lowering homocysteine levels with B vitamins on cardiovascular disease. Circulation 2010. Njolstad I. Homocysteine in disease: results of a randomized controlled trial. Bias in meta-analysis detected by a simple.6:e1000097. Cardiovascular 2010. Johnson and mortality: meta-analysis of 8 randomized trials involving 37 485 individuals. major morbidity in myocardial infarction survivors: a randomized trial. Am J Clin Nutr 2 Nerbass FB. Homocysteine 2006. Warren SR. randomized. Ethical approval: Not required. et al. Pao K-Y. Branley P. 32 The VITATOPS Trial Study Group. Homocysteine-lowering and cardiovascular disease outcomes in kidney transplant activities. Fodor G. Endler G. AC. Cochrane Collaboration.54:478-89. Hornberger JM. Arnold JMO. et al. J Am Soc Nephrol 2005. Sheridan P. Challier B. BMJ 2002. Greenwood R. all cause mortality. Pauly M. Chalopin JM. Delfino VA. creatinine clearance on plasma homocysteine in hypertensive patients with normal serum 27 Ganji V.26:259-65. Bulbulia R. Davey Smith G. McQueen MJ. Greene T. N Engl J Med 2006. Wolfe R. Pfeffer MA. et al. JAMA 8 Zoungas S. Dierkes J. (ASFAST) in chronic renal failure: a multicenter. 2005. and Servier and has received payment for lectures Med 2010. KDOQI Guidelines. Curhan GC. AK. and MSD. Goldsmith D.org/professionals/kdoqi/guidelines_cvd/homocystein. disease.1. total plasma homocysteine is an indicator of poor outcome in hemodialysis patients. Luley CMD. Homocysteine lowering received payment for lectures from Roche. lowering with folic acid and B vitamins in people with chronic kidney disease—results of 5 Ducloux D. Epidemiology: study design and data analysis. Bragg-Gresham JL. Jinming L. Domrose UMD. Kropf SP. Bowman L.291:565-75. Rahimi K. Homocysteine as a risk factor for cardiovascular MJ has received an unrestricted grant from CSL. D’Addio F. Arnold MJ.23:645-53. Chapman and 1 Lin Y-H. Carpenter MA. Homocysteine and cardiovascular disease: evidence on htm. et al. Homocysteine transplant recipients: a prospective study. [Article]. received a KL2 grant from the National Institutes of Health. et al. Luley C. B vitamins in patients with recent transient ischaemic 7 Jamison RL. JAMA 33 House A.106:267-70. and Servier International. Kidney Int 29 Vianna ACA. Beck GJ. Kropf S. Novo Nordisk. Wallendszus K. PLoS Med VP are affiliated with the George Institute. with no evidence of heterogeneity Our findings suggest that folic acid based homocysteine lowering should not be used for cardiovascular prevention in people with kidney disease Competing interests: All authors have completed the ICMJE uniform 13 Bonaa KH. J Inherit Metab Dis 2003.121:1432-8. Wang X. Chandraker A. J Am Soc Nephrol.15:420-6. hemodialysis patients. Ueland PM. Goldfarb DS.org/coi_disclosure. and death: the Vitamin Intervention for Stroke Prevention (VISP) advisory boards for MSD. JAMA 2002. et al. Effect of folic acid supplementation on risk and has received consultancies from Novo Nordisk and Johnson and of cardiovascular diseases: a meta-analysis of randomized controlled trials. J Am Diet Assoc 28 Heinz JM.303:2486-94. La Manna G. The influence of estimated Hall/CRC Press. JAMA Johnson. Schirmer H. Persici E. Feiten SF. Coli L. Kopple JD. Spence JD. Am J Kidney Dis 2009. Micks M. or access thrombosis The results were consistent across categories of kidney disease (end stage kidney disease. VP is a member of the Abbot 20 Clarke R. Borucki KMD. and its determinants in nondialyzed chronic kidney disease patients. Fine A. Morais-Filho D. Sheridan P.bmj.303:1603-9. MJ. BMJ 1997. cardiovascular events.bmj. et al. Egger M. Homocysteine and risk of ischemic heart disease 2010. NFK J Am Soc Nephrol 2004. from any organisation for the submitted work. Mocelin AJ. causality from a meta-analysis. Muske C. www. version 5. 2005.com/subscribe . Oliver M. McGrath BP. Motte G. has grants or grants pending from Roche. received an educational grant from Shire. 9 Righetti M. and no other relationships or activities that transplantation trial. et al.kidney. Tetzlaff J. Howard VJ. Pettigrew LC.325:1202. 26 Woodward M. Clarke RJ. therapy on progression of diabetic nephropathy: a randomized controlled trial.org/Clinical/GuidelinesSection/CardiovascularDiseaseInCKD.47:1108-16. speakers fees from MSD. et al. Ethier J. Gibey R. cancer. Arch Intern Johnson.44(5 suppl 2):61-7. received payment for lectures from Roche Pharmaceuticals. Homocysteine lowering and cardiovascular events after acute myocardial infarction. MG has J Clin Pract 2010. Halsey J. Malinow MR. decreases cardiovascular events in hemodialysis patients. Servier. Kramar R. Draibe SA.354:1567-77.298:1163-70. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. and functioning kidney transplant). Sterne JAC. Churchill D. 10 Kalantar-Zadeh K. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke. www. 19 Heinz J. 12 Homocysteine Studies Collaboration. concentrations in US adults after the fortification of cereals with folic acid. chronic kidney disease: effect of low protein diet and repletion with B vitamins.icmje. Reynolds K. Clin Biochem 2007. Effects prospective study. Effect of homocysteine interventions on the Novartis.0 [updated March 2011]. 11 Wald DS. Concord Hospital has disease in patients treated by dialysis: a meta-analysis. Hunsicker L. 2006. cardiovascular disease occurrence in chronic. Armitage J. of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and 6 Wrone EM. Cochrane handbook for systematic reviews of interventions could appear to have influenced the submitted work. et al. Blood Purif Dialysis Outcomes and Practice Patterns Study (DOPPS) data on medications in 2006. Am J Kidney Dis 2004. 24 Harbord RM. Eliasziw M. J Am Coll 5-methyltetrahydrofolate administration is associated with prolonged survival and reduced Cardiol 2006. Serbelloni P. cardiovascular mortality. J Am Soc Nephrol 2004.24:379-86. Cardiovascular disease in CKD. 2011. Int development of educational presentations from Medi Mark. 16 Mei W. disease and end-stage renal disease: a randomized controlled trial. SDN has 17 Yap S. Classical homocystinuria: vascular risk and its prevention. Holder KN. rather than 36 KDOQI Clinical Practice Guidelines for Cardiovascular Disease in Dialysis Patients: section a high. Hui Z. AC has 18 Lonn E.11:210-6. and Astra Zeneca.296:2720-6. Hemodial Int 2007. Chien Y-F. 23 JPT Higgins. Vannucchi H. requirement for dialysis treatment. Hartigan P. Yongjun L. Schneider M. Guidelines: UK Renal Association. and payment for the risk of cardiocerebrovascular events: a meta-analysis of randomised controlled trials. Liberati A. The PG. N Engl J Med disclosure form at www. Green S (eds). myocardial infarction. Cattran D. Manson JE. JAMA 2004. Lancet Neurol 2010. Altman DG. Fortmann SP. No commercial reuse: See rights and reprints http://www. Chambless LE. Stat Med 2006. and Boehringer Ingelheim. Summary2.354:1578-88. SZ. McCann LM. Novo Nordisk. Levey AS. Serum total homocysteine and the renal Hope-2 study. stroke. Fissell RB.315:629-34. Cuppari L. stable renal transplant recipients: a 31 Armitage JM.67:1539-46. et al. Lonn E. 25 Egger M. Fodinger M. Effect of B-vitamin 2007. Data sharing: No additional data available. controlled trial. Kaufman JS. which receives funding from 2009. request from the corresponding author) and declare that : no support 14 Toole JF. chronic kidney disease. Rong Y.123:1763-70. 2000. from Roche. Ferrario G. Law M.40:230-4.pdf (available on 2006. Coplon NS. et al. Astra Zeneca/BMS. Largura A. Minder C. Kafai MR. Population reference values for plasma total homocysteine creatinine. Kerr PG. Sanofi Aventis. Baxter. MG. Steigen T. 2nd ed.1136/bmj.16:255-60.84:989-94. Zehnder JL. [see comment]. and cause-specific advisory board. Morbidity and Mortality in the Atherosclerosis and Folic Acid Supplementation Trial 34 Cianciolo G. Servier. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Held C. Pogue J. Yusuf S. TN.28:941-8.com/permissions Subscribe: http://www. et al.344:e3533 doi: 10. He J. et al. III. Kusek JW. Hung C-S. Am J Nephrol 2008. 15 Bazzano LA. et al. Donati G. Uremic 2005. State of the science: novel and controversial topics in cardiovascular diseases.e3533 (Published 13 June 2012) Page 6 of 11 RESEARCH What is already known on this topic Elevated homocysteine levels are associated with an increased risk of cardiovascular events Homocysteine lowering in the general population has failed to show clear cardiovascular benefits unlike the situation with people with homocysteinuria who have noticeably increased homocysteine levels Homocysteine levels increase as estimated glomerular filtration rate levels decline What this study adds In over 10 000 people with a range of severity of kidney disease no benefit was seen from folic acid based homocysteine lowering therapy for cardiovascular events. McAllister CJ. Block G. Morris JK. Effect attack or stroke in the VITAmins TO Prevent Stroke (VITATOPS) trial: a randomised. various pharmaceutical companies to support parts of its research 22 Bostom AG. Tverdal A.

47 Suliman M. Dennis V. No commercial reuse: See rights and reprints http://www. et al.6:482-8. which permits use.0/legalcode. Nemirovsky D.344:e3533 doi: 10.114:c5-11.344:e3533 homocysteine levels in patients with end-stage renal disease. K/DOQI clinical practice guidelines for cardiovascular disease in transplant recipients. Hou F. et al. Qin X.com/permissions Subscribe: http://www. Cunningham R. Barany P.9:1103-8. et al. Folic acid therapy and 2008. Matossian D. Arnolda LF. cardiovascular disease in ESRD or advanced chronic kidney disease: a meta-analysis. 49 Silva de Almeida CC. Kalantar-Zadeh K. Geleilete TJM. et al.82:806-12. Efficacy of folic acid supplementation 48 Potter K. Circulation 2006. Vannucchi MTI. Chiarello Clin J Am Soc Nephrol 2011. Guerra DC. Eikelboom JW.14:828-33. al. The phenomenon of altered risk factor patterns or reverse epidemiology in is otherwise in compliance with the license. Bader CA. et Clin Nutr 2005. Sarnak MJ.113:1572-7. Hankey GJ. Homocysteine or renal in stroke prevention: a meta-analysis. and reproduction in 45 Menon V. nc/2. Hyperhomocysteinaemia: a significant risk factor for cardiovascular disease in renal 41 K/DOQI Workgroup.369:1876-82. Qureshi AR. impairment. Geer EB. Chadefaux-Vekemans B. Circulation 1996. The reverse epidemiology of plasma total homocysteine as a mortality risk factor is related to the impact of wasting and inflammation.com/subscribe .22:209-17.81:1257-66.1136/bmj.org/licenses/by- persons with advanced chronic kidney failure. [see comment].bmj. Eknoyan G.bmj. the use is non commercial and 46 Kopple JD. Hyperhomocysteinemia confers an independent increased risk of atherosclerosis in Accepted: 8 May 2012 end-stage renal disease and is closely linked to plasma folate and pyridoxine concentrations. Beck GJ. 44 Nair AP. blood concentrations of homocysteine: a meta-analysis of the randomized trials. Heimburger O. Kim M. which is the real cardiovascular risk factor? Arterioscler Thromb Vasc Biol 39 Qin X. Arheart K.org/licenses/by-nc/2. 43 Robinson K. Chen Y.45(4 suppl 3):S1-153. Stenvinkel P. Huo Y.94:2743-8.21:394-400. Relationship between homocysteine and mortality in chronic kidney disease. PG. What is the meaning of homocysteine in patients on dialysis? J Ren Nutr 40 Homocysteine Lowering Trialists Collaboration. See: http://creativecommons.BMJ 2012. Nephron Clin Pract 2010. provided the original work is properly cited. Farkouh ME. Vannucchi H. et al. Mt Sinai J Med This is an open-access article distributed under the terms of the Creative Commons 2005. Drueke TB. Gupta A. Green R. recipients. Maxwell AP. homocysteine is a predictor of all-cause mortality in a prospective cohort of renal transplant Nephrol Dial Transplant 1999.0/ and http://creativecommons. Elevated 42 Levey AS. Greene T. Young IS. Elevated Cite this as: BMJ 2012. McNamee PT. Nephrol Dial Transplant 1994. Pereira AA. Green DJ. Demirtas H. Legendre C. Chaudhary D.72:365-73. Chevalier A. Langman CB. Am J Kidney Dis 2005. 51 Connolly GM. Winston J. Am J 50 Massy ZA. Cardiovascular disease in chronic renal disease. Nephrol Dial Transplant 2007. Li J.28:1158-64. Huo Y. Dose-dependent effects of folic acid on 2011. Mao G. any medium. et al. Am J Clin Nutr 2005.e3533 (Published 13 June 2012) Page 7 of 11 RESEARCH 38 Wang X. dialysis patients. Attribution Non-commercial License. Wang X. distribution. Lancet 2007.

2¶¶¶ 83¶¶¶ 1267 1686 Myocardial NR NR 2 mg folic acid. carotid endarterectomy. 25 mg all cause vitamin B6.8 98 1129 (55) 511 (25)†† Myocardial 24. stroke.9 15 mg or 5 mg 1 mg folic acid Yes (100) infarction. vitamin B12 amputation daily Vianna 200729 ESKD ESKD 186 48.1 17. stroke. CKD infarction. 48 (15)** cardiovascular death Righetti 20069 ESKD (HD) ESKD 88 64. folic acid daily¶ death.9 24.1)§ Myocardial 15. 50 µg B12. 2mg (63)¶¶ mortality. 50 mg (CKD 11%) cardiovascular vitamin B6. Placebo No 80 (SEARCH)*** myocardial (100)††† (11)¶¶¶ (100)††¶¶¶ infarction. haemodialysis arrhythmias. stroke. heart failure Mann 200830 Vascular CKD 619 72.2 50 232 (45) 174 (34)§ Myocardial 32.BMJ 2012. acid. unstable haemodialysis haemodialysis angina. 100 mg 1305 all cause vitamin B6. transient ischaemic attack.344:e3533 doi: 10.5‡‡ 15 mg folic acid Placebo No (ASFAST) (85). stroke. acid. stroke. vitamin B12 revascularisation Armitage 201031 History of CKD 1686 64. revascularisation Heinz 201028 ESKD ESKD 650 61.2 67 269 (43) 537 (87)§ Myocardial 15. 0. B6 250 mg. CKD infarction.0 58 262 (40) 312 (48) Myocardial 29 18. stroke. B12 500 mg) if plasma B12 depleted Jamison 20077 ESKD and CKD ESKD 751 65. angina. 1 mg vitamin infarction coronary heart B12 disease death.6 56 17 (19) 51 (58)§ Myocardial 34. 1mg mortality.1136/bmj. 20 acid. revascularisation. 1 death mg vitamin B12 House 201033 Diabetic CKD 238 60.bmj.4 75 238 (100) 74 (31.8 40 mg folic Placebo Yes (HOST) (37). stroke.3 2. peripheral arterial disease.8 11.8 5 mg folic acid. No commercial reuse: See rights and reprints http://www.0‡‡ NR 10 mg folic acid Placebo No (100) infarction.2 mg folic No (100) infarction.com/subscribe .5 mg folic Placebo Partial‡‡‡ (HOPE 2)*** disease or DM (100)††† infarction. sudden cardiac mg B6 after 1 mg B6 after death.6 Folic acid 5 mg Usual care No (100) infarction. amputation Zoungas 20068 ESKD and CKD ESKD 267 56.5 59 42 (23) 44 (24)§ Myocardial 25. daily or 2nd sudden cardiac daily according death. to folic acid carotid levels+vitamin endarterectomy in B complex 2nd patients with daily (B1 250 symptoms§§ mg. stroke. 3 times per cardiovascular week after death.com/permissions Subscribe: http://www.5 mg folic Placebo Yes (DIVINe) nephropathy§§§ (100) infarction.bmj. pulmonary embolism. angina.e3533 (Published 13 June 2012) Page 8 of 11 RESEARCH Table Table 1| Characteristics of studies reporting effect of folic acid based homocysteine lowering therapy in people with kidney disease Category No (%) Mean homocysteine* of kidney Mean No (%) with Components of (µmol) M Study disease age % with cardiac cardiovascular Study Grain fol Study population No (%) (years) male diabetes disease composite Baseline Achieved† intervention‡ Comparison fortification (m Wrone 2004 6 ESKD ESKD 510 60. coronary revascularisation.6 22. 4 µg B12.2 68 73 (23) 35 (11)†† Myocardial 27 21. stroke.5 13. acid.9 2.

resuscitated sudden death. 1 mg µg B12 recipients cardiovascular B12 disease death.4 mmol/L. ¶¶¶Data for chronic kidney disease subgroup not available. ****Mean reported.6¶¶¶ 64¶¶¶ 1899 598 Myocardial NR NR 2 mg folic acid. stroke. ‡‡‡‡Based on a sample of 72 participants in the intervention group. *Homocysteine levels not included if not available for subgroup with chronic kidney disease. For the current analysis.com/subscribe . NR:=not reported. defined as serum creatinine concentration ≥0. No commercial reuse: See rights and reprints http://www. ¶Study design had two intervention arms and one “standard care” arm.0 Yes 4 (FAVORIT) transplant (100) (40. §§§Participants with chronic kidney disease stage 4 and 5 were excluded by design.5) infarction.bmj. Participants with severe renal disease (serum creatinine level >2× upper limit of normal) were excluded by design. ‡‡Median reported. 0. KTR=functioning kidney transplant recipient. above ankle amputation. ESKD=dialysis dependent end stage kidney disease. §Cardiac disease as defined by study author. †In intervention group. two intervention arms are combined.0)§ Myocardial 16. ††Cardiac disease defined as previous myocardial infarction.com/permissions Subscribe: http://www.5 mg death vitamin B12 Bostom 201122 Kidney KTR 4110 52 63 1663 820 (20.1136/bmj. 2. †††MDRD estimated glomerular filtration rate <60 ml/min.4 11. Placebo Partial‡‡‡ 4 (VITATOPS)*** preceding 7 (100)†††† (24)¶¶¶ (7)‡‡¶¶¶ infarction.e3533 (Published 13 June 2012) Page 9 of 11 RESEARCH (continued) Category No (%) Mean homocysteine* of kidney Mean No (%) with Components of (µmol) M Study disease age % with cardiac cardiovascular Study Grain fol Study population No (%) (years) male diabetes disease composite Baseline Achieved† intervention‡ Comparison fortification (m thromboses excluding shunt thromboses Hankey 201032 Stroke or TIA in CKD 493 62.BMJ 2012. ¶¶Chronic kidney disease defined as Cockcroft-Gault estimated glomerular filtration rate ≤30 ml/min. §§Cardiovascular composite not reported separately for randomised and observed participants. ***Chronic kidney disease subgroup of larger trial. repair of abdominal aortic aneurysm CKD=predialysis chronic kidney disease. revascularisation. ‡Daily unless stated otherwise.8‡‡‡‡ 5 mg folic acid. **Non-dialysis dependent chronic kidney disease. 1.4 mg B6. ‡‡‡Grain fortification in some but not all trial countries. stroke.344:e3533 doi: 10. ††††Chronic kidney disease defined as serum creatinine concentration >120 µmol/L. 50 mg B6. 25 mg vitamin months cardiovascular B6. data for total study reported.bmj.

com/permissions Subscribe: http://www.bmj.bmj.344:e3533 doi: 10.com/subscribe .e3533 (Published 13 June 2012) Page 10 of 11 RESEARCH Figures Fig 1 Identification process for eligible studies Fig 2 Effect of folic acid based homocysteine lowering therapy on composite cardiovascular events No commercial reuse: See rights and reprints http://www.1136/bmj.BMJ 2012.

BMJ 2012.e3533 (Published 13 June 2012) Page 11 of 11 RESEARCH Fig 3 Subgroup analyses for effect of homocysteine lowering on cardiovascular events. Data reported as ‘”not available” applied to chronic kidney disease subgroups of relevant studies No commercial reuse: See rights and reprints http://www.bmj.344:e3533 doi: 10.com/subscribe .1136/bmj.com/permissions Subscribe: http://www.bmj.