Summary of findings for the main comparison. Calcineurin inhibitor (CNI) withdrawal versus standard dose CNI for kidney transplant recipients.
| CNI withdrawal versus standard dose CNI for kidney transplant recipients | |||||
| Patient or population: kidney transplant recipients Intervention: CNI withdrawal Comparison: standard dose CNI | |||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | No. of participants (studies) | Quality of the evidence (GRADE) | |
| Risk with standard dose CNI | Risk with CNI withdrawal | ||||
| Death Follow‐up: range 9 months to 20 years | Study population | RR 1.09 (0.96 to 1.24) | 2010 (14 ) | ⊕⊕⊕⊝ MODERATE 1 2 3 4 | |
| 225 per 1,000 | 245 per 1,000 (216 to 279) | ||||
| Acute rejection Follow‐up: range 9 months to 15 years | Study population | RR 2.54 (1.56 to 4.12) | 1666 (15) | ⊕⊕⊕⊝ MODERATE 2 4 5 6 | |
| 137 per 1,000 | 348 per 1,000 (214 to 564) | ||||
| GFR Follow‐up: range 1 to 15 years | The mean GFR in the intervention group was 3.56 mL/min more (1.13 less to 8.25 more) than the control group |
‐ | 910 (8) | ⊕⊕⊝⊝ LOW 7 8 | |
| Graft loss Follow‐up: range 9 months to 20 years | Study population | RR 0.85 (0.74 to 0.98) | 2090 (16) | ⊕⊕⊝⊝ LOW 1 2 9 10 11 12 | |
| 236 per 1,000 | 201 per 1,000 (175 to 231) | ||||
| Adverse events: hypertension Follow‐up: range 1 to 15 years | Study population | RR 0.82 (0.71 to 0.95) | 950 (5 ) | ⊕⊕⊝⊝ LOW 2 10 | |
| 555 per 1,000 | 455 per 1,000 (394 to 527) | ||||
| Adverse events: CMV infection Follow‐up: range 9 months to 15 years | Study population | RR 0.87 (0.52 to 1.45) | 608 (7) | ⊕⊕⊝⊝ LOW 1 2 10 | |
| 98 per 1,000 | 86 per 1,000 (51 to 143) | ||||
| Adverse events: malignancy Follow‐up: range 1 to 15 years | Study population | RR 1.10 (0.93 to 1.30) | 1079 (6) | ⊕⊕⊝⊝ LOW 1 2 4 10 | |
| 257 per 1,000 | 282 per 1,000 (239 to 334) | ||||
| *The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio | |||||
| GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect | |||||
1 despite different follow up times, heterogeneity not noted on analysis
2 Most studies were ITT analysis, some small studies did not specify randomisation and allocation concealment
3 Larger studies closer to pooled estimate on funnel plot
4 Some studies were small with large confidence intervals, CI fails to exclude benefit or harm
5 Heterogeneity low when biopsy‐proven rejections were analysed in subgroup
6 Smaller studies not distributed around point estimate
7 Significant heterogeneity noted despite separating time periods of reporting GFR
8 Only few studies reported GFR with possible attrition bias
9 2 large studies had more than 2 comparison groups
10 Very few studies reported the outcome
11 Symmetric distribution studies around estimate of effect
12 2 studies with high event rates skew the effect