Helicobacter pylori An infection in Dialysis Sufferers: A Meta-Evaluation

Helicobacter pylori Infection in Dialysis Patients: A Meta-Analysis
November 12, 2020 0 Comments

Background. An infection with Helicobacter pylori contributes to the etiopathogenesis of varied extragastrointestinal circumstances, but its etiological affiliation with both symptomatic or asymptomatic dialysis sufferers stays inconclusive. Strategies. Two researchers working independently carried out a literature search of the web databases PubMed, EMBase, ScienceDirect, and Cochrane Central Register of Managed Trials to establish related articles to the top of 2012. Case-control and cross-sectional research that met the inclusion standards had been included. Outcomes. Fifteen research involving 1237 dialysis sufferers and 1568 controls with regular renal operate had been included. In contrast with regular controls, dialysis sufferers general had been related to a comparatively decrease danger of H. pylori an infection although not statistically vital. A big inverse affiliation was discovered between H. pylori prevalence and period of therapies in those that had been dialyzed >4 years (odds ratio 0.28; 95% confidence interval 0.22–0.36, ). No relationship between H. pylori standing and period of dialysis was noticed in CRF sufferers. There have been no vital variations in endoscopic options between sufferers and controls. Conclusions. Our meta-analysis discovered no proof of a major affiliation between an infection with H. pylori and dialysis general, whereas long-term therapies of greater than 4 years had a major protecting impact.

1. Introduction

Helicobacter pylori, an infectious organism, is current in about 50% of the worldwide inhabitants, and the an infection ranges exceed 70% in some creating areas [1]. An infection with H. pylori has been implicated not solely within the etiopathogenesis of gastrointestinal illness, equivalent to gastritis, ulcerative ailments, low-grade mucosa-associated lymphoid tissue lymphoma, and gastric malignancies [2], but in addition in varied extragastrointestinal circumstances, amongst them power renal illness [3].

From 25% to 75% of power renal failure (CRF) sufferers who obtain hemodialysis or steady ambulatory peritoneal dialysis (CAPD) for lengthy durations expertise gastrointestinal troubles [4]. It has been postulated that prime urea focus makes the gastric mucosa of those sufferers extra prone to colonization by H. pylori [5]. Nonetheless, an etiological affiliation between H. pylori and both symptomatic or asymptomatic dialysis sufferers stays inconclusive.

The prevalence of H. pylori an infection in CRF sufferers could also be as excessive as 64% and considerably greater in dialysis sufferers than in regular controls [6–9]. Others [10–12] report fairly the alternative. Many elements would appear to contribute to the inhibition of H. pylori progress within the abdomen of CRF sufferers (e.g., greater ranges of proinflammatory cytokines, impaired immune system, elevated pH, greater blood urea ranges, and antibiotic remedy). Nonetheless, some research [13–19] discovered no distinction within the prevalence of H. pylori an infection between sufferers on dialysis and wholesome controls, resulting in the conclusion that the extent of urea will not be a danger issue predisposing to H. pylori an infection on this inhabitants. Due to these conflicting stories, the seriousness of H. pylori an infection in dialysis sufferers stays unclear.

The variety of dialysis sufferers will increase by 7% yearly [20], and it’s subsequently crucial to resolve some necessary points regarding H. pylori an infection in dialysis sufferers. The current research is a meta-analysis, designed to assist make clear the prevalence of H. pylori in CRF sufferers in addition to the connection between dialysis period and the prevalence of H. pylori. As well as, H. pylori standing in CRF sufferers and the course of dialysis can be mentioned.

2. Supplies and Strategies

2.1. Literature Sources and Searches

We systematically searched the databases MEDLINE, EMBASE, ScienceDirect, and Cochrane Central Register of Managed Trials (CENTRAL) for related articles and abstracts printed in English (ending 31 December 2012). Phrases and key phrases used to establish articles in Medical Topic Headings (MeSH) had been Helicobacter pylori/H. pylori, and dialysis ((“Helicobacter pylori” OR “H. pylori”) AND “dialysis”). Two reviewers (MG and SPX) manually screened every eligible article’s title, summary, and full textual content to independently decide if the article met the inclusion standards (under). Variations between the reviewers had been solved by consensus.

2.2. Inclusion and Exclusion Standards

For inclusion within the meta-analysis, case-control or cross-sectional research needed to report knowledge on the speed of H. pylori an infection in sufferers with and with out dialysis and embody a management group with regular renal operate; base analysis of H. pylori an infection on histology (e.g., Giemsa stain or Warthin-Starry technique), tradition, immunoglobulin G (IgG) antibody detection, speedy urease check, or urea breath check; concern human topics solely; and be printed in English. Research had been excluded that had been case stories, observational research with out management teams, overview of the literature, or duplicated stories; if knowledge on H. pylori an infection within the dialysis group or management group was incomplete or unavailable; or if topics had a historical past of drug use for antibiotics, H2 blockers, proton pump inhibitors, or bismuth inside 4 weeks.

2.3. Information Extraction

Two unbiased reviewers extracted the knowledge from the included articles. Discrepancies within the extraction had been resolved by mutual dialogue. For every research, the next knowledge had been collected: writer; publication 12 months; nation; research design; fundamental traits of sufferers together with variety of sufferers with and with out dialysis and sort and period of dialysis; detection strategies for H. pylori an infection and endoscopic abnormalities.

2.4. Information Evaluation

The software program Overview Supervisor (RevMan, model 5.1, Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011) was used to research the information. We organized eligible articles chronologically, beginning with the earliest. The percentages ratios (ORs) and their 95% confidence intervals (CIs) for main outcomes had been estimated in a hard and fast mannequin or random mannequin for every research. Statistical heterogeneity was evaluated with the statistic, and % indicated substantial heterogeneity [29], through which case the situation random results mannequin was used. The variations had been thought-about statistically vital when a worth was lower than 0.05.

3. Outcomes

3.1. Primary Data and Traits

The literature search initially yielded 152 articles related to the subject (Determine 1). Eighty-eight of those had been excluded for not assembly the inclusion standards. The total texts of the remaining 64 citations had been fastidiously reviewed. Finally, 49 of the 64 had been excluded as a consequence of the usage of sure medicine inside 4 weeks or for assembly some other of the exclusion standards. This course of left 15 certified essays (Desk 1).

Writer (ref.) Yr Nation Examine design Age, y Check confirming an infection Period of dialysis, m Dialysis sort, HP(+),

CAPD Controls Dialysis

Shousha et al. [13] 1990 UK Case-control HP(+) 54 ± 14.3
HP(−) 48 ± 14.2
Warthin-Starry, Giemsa NG NG NG 51/120 12/50
Jaspersen et al. [10] 1995 Germany Case-control 58.2 ± 12.6 Urease check, Giemsa NG 7/34 0 47/127 7/34
Krawczyk et al. [14] 1996 Poland Case-control 36.8 ± 13.2 Urease check, Giemsa 28 ± 12.2 13/21 0 14/22 13/21
Ozgür et al. [15] 1997 Turkey Case-control 37.27 ± 14.08 Urease check 28.87 ± 28.92 28/47 0 64/100 28/47
Gür et al. [21] 1999 Turkey Case-control HP(+) 35.1 ± 4.2
HP(−) 32.5 ± 5.3
Urease check, histology HP(+) 21.2 ± 16.4
HP(−) 21.8 ± 11.4
25/45 0 24/44 25/45
Araki et al. [4] 1999 Japan Case-control 57.4 ± 12.8 Histology, tradition 91.2 ± 62.4 NG/54 NG/9 42/64 29/63
Yildiz et al. [22] 1999 Turkey Cross-sectional 36.6 ± 15.2 ELISA (IgG) 32.5 ± 27.7 NG NG 39/55 31/47
Tamura et al. [23] 1999 Japan Case-control 52.2 ± 1.8 Urease check, histology, and tradition 29.3 ± 5.4 20/41 5/8 26/48 25/49
Blusiewicz et al. [24] 2005 Poland Case-control 50.8 ± 2.9 Urease check, histology NG 19/30 0 22/31 19/30
Khedmat et al. [6] 2007 Iran Case-control 47.9 ± 3.5 Urease check 46.9 ± 10.7 46/73 0 106/305 46/73
Khazaei et al. [25] 2008 Iran Case-control 14.7 ± 3.4 Urease check, histology HP(+) 22.5 ± 18.5
HP(−) 26.9 ± 32.5
16/24 0 5/25 16/24
Gioè et al. [26] 2008 Italy Case-control NG RUT, Giemsa NG 75/142 0 59/132 75/142
Asl and Nasri [27] 2009 Iran Cross-sectional 56 ± 14 Giemsa ≥6 28/40 0 23/40 28/40
Sugimoto et al. [11] 2009 Japan Case-control 58.8 ± 0.4 ELISA (IgG) 100.8 ± 3.6 NG NG 314/400 262/539
Chang et al. [28] 2010 Korea Case-control 62 ± 9.8 RUT, histology HP(+) 56.8 ± 26.9
HP(−) 66.4 ± 26.1
12/33 0 36/55 12/33

Ref.: reference; HD: hemodialysis; CAPD: steady ambulatory peritoneal dialysis; NG: not given; RUT: speedy urease check.
3.2. Total Evaluation

These 15 articles comprised 1237 dialysis sufferers and 1568 controls with regular renal operate. Since I2 was larger than 50%, a random mannequin was utilized. Pooled knowledge confirmed that there was no distinction in H. pylori prevalence between the dialysis (hemodialysis and CAPD) sufferers and regular controls (OR = 0.86, 95% CI: 0.52–1.42, ; Determine 2(a)). A subanalysis confirmed no distinction in H. pylori an infection between sufferers receiving hemodialysis and the management group (OR = 1.11, 95% CI: 0.69–1.81, ; Determine 2(b)). A funnel plot indicated that there was no publication bias (Determine 3).

On this meta-analysis, varied strategies had been adopted to verify H. pylori an infection as acknowledged beforehand. As everyone knows, IgG antibody detection can not decide current an infection of H. pylori, since serum antibodies particular to H. pylori would nonetheless stay for a number of months after profitable eradication, nonetheless; serology is the one check which isn’t affected by native modifications within the abdomen that might result in a low bacterial load and to false unfavourable outcomes of the opposite exams and it’s the third technique generally used as a noninvasive technique to diagnose H. pylori an infection [30]. In an effort to exclude the chance that totally different strategies for H. pylori detection would result in totally different outcomes, we selected to exclude 2 articles [11, 22] which solely utilized IgG to detect H. pylori an infection. Nonetheless, subsequent evaluation once more discovered no variations between the 2 teams (Determine 4). Nonetheless, we wished to detect if different detection strategies like speedy urease check (RUT) would affect the general evaluation, whereas a couple of form of detection technique was concerned within the different research included in our meta-analysis. The info of different detection strategies can’t be analyzed individually.

3.3. Impact of Dialysis Period on H. pylori Prevalence

Some research have indicated that the speed of H. pylori an infection decreases over a chronic course of hemodialysis. Therefore we carried out a subgroup meta-analysis of H. pylori an infection and the period of dialysis (Figures 5(a) and 5(b)). Those that underwent dialysis longer than 4 years [4, 11, 28] certainly confirmed a considerably decrease price of H. pylori an infection () than these with regular renal operate, whereas it’s one other story on the subject of those that endured dialysis period shorter than 4 years [6, 14, 15, 21–23, 25] () with no distinction in H. pylori an infection price between two teams.

3.4. Impact of H. pylori Standing on Period of Dialysis

Just a few earlier research have proven that H. pylori optimistic sufferers required a considerably shorter course of dialysis than uninfected sufferers [22, 31]. Among the many included research, 5 research [4, 15, 21, 22, 25, 28] evaluated the connection between H. pylori standing and period of dialysis. Nonetheless, no statistical significance was noticed between H. pylori unfavourable and H. pylori optimistic sufferers. The weighted imply distinction between these research was 4.56 (95% CI: −1.55–10.67, ) (Determine 6).

3.5. Endoscopic Findings

We in contrast the endoscopic findings between the dialysis and management teams, primarily regarding gastritis and ulcerative ailments. Ten research [4, 6, 10, 11, 13, 15, 21, 24, 26, 28] offered detailed endoscopic data relating to, for instance, gastritis, ulcerative ailments, and intestinal metaplasia. The incidence of gastritis and ulcerative ailments in dialysis sufferers and regular controls was 66.2% versus 56.2% () and 13.7% versus 24.9% (), respectively. There aren’t any vital variations in endoscopic abnormities between the dialysis sufferers and the controls with regular renal operate (Figures 7(a) and seven(b)).

4. Dialogue

Not too long ago, an increasing number of proof has proven that H. pylori is said to extragastrointestinal ailments equivalent to iron deficiency anemia, idiopathic thrombocytopenic purpura [32], and diabetes mellitus [33]. Furthermore, sufferers with CRF normally endure from systemic or native power circulatory failure (or each) [34], hypergastrinemia [21], excessive ammonia ranges [35], and enhanced irritation that facilitates H. pylori an infection. Within the current research, we carried out a meta-analysis and located that CRF sufferers on dialysis remedy had an general H. pylori an infection price of ~50.8%, which was comparatively however not considerably decrease than the 55.6% in controls ().

Upon investigating the affiliation between H. pylori an infection and the several types of dialysis, we discovered that H. pylori an infection was not statistically related to hemodialysis particularly. Nonetheless, the H. pylori an infection price within the hemodialysis group (54.5%) was barely greater than that of the management (45.9%), which contrasts with the outcomes of the general evaluation. Resulting from lack of knowledge, we weren’t in a position to analyze the distinction in H. pylori prevalence between CRF sufferers present process CAPD and people receiving hemodialysis. Thus, our outcomes from these research revealed that the prevalence of H. pylori an infection is comparable between CRF sufferers who had been receiving dialysis and the management group with regular renal operate ().

From the outcomes of the current research, it seems that CRF remedy with dialysis doesn’t change the chance of H. pylori an infection. Though one researcher went towards present thought and concluded that the extent of urea will not be a danger think about H. pylori colonization [28], neither idea has proved definitive and extra analysis is required to make clear the problem. Among the many included research in our meta-analysis, some researchers [4, 11, 13, 28] discovered that the prevalence of H. pylori in CRF sufferers present process dialysis was considerably decrease than in non-CRF controls with or with out gastrointestinal signs. The reality is that many CRF sufferers who obtain dialysis inevitably have entry to antibiotics, proton pump inhibitors, or H2 receptor antagonists which then affect the H. pylori an infection price to some extent [13, 36]. Furthermore, gastric atrophy progresses together with decreased secretion of acid [37] in addition to greater ranges of proinflammatory cytokines [38] in CRF sufferers, making H. pylori tough to outlive. Aside from these, the prevalence of H. pylori varies extensively throughout totally different demographic and geographic areas as a consequence of financial conditions, sanitary circumstances, cultural habits, and extra.

Our subgroup evaluation revealed that the prevalence of H. pylori of these sufferers who had been on dialysis for longer than 4 years was considerably decrease than of people with regular renal operate, whereas the period of dialysis between H. pylori unfavourable and H. pylori optimistic sufferers didn’t differ from one another. It’s in accordance with different research. Sugimoto et al. [11] confirmed that the prevalence of H. pylori an infection decreased within the first 4 years of dialysis and plateaued after 5 years of remedy and it was not affected by basement ailments. He and his colleagues concluded that greater than one-third of sufferers who had obtained roughly 4 years of dialysis therapies had been naturally cured of H. pylori infections. Nakajima et al. [31] additionally reported that the prevalence of H. pylori decreased together with prolonged hemodialysis period of two years and extra. They declared that the discount of H. pylori prevalence in long-term dialysis sufferers was as a consequence of discount of gastric acid secretion associated to power gastritis or frequent antibiotic consumption. Nonetheless there are literally conflicts in regards to the relationship between H. pylori standing and period of dialysis. A number of research argued that period of dialysis was inversely associated to H. pylori colonization in dialysis sufferers [39–41], and a few discovered an reverse outcome [42]. But, the underlying mechanism remains to be obscure. Extra investigations are warranted to be carried out to elucidate these findings sooner or later.

Endoscopic abnormities equivalent to erosive gastritis, duodenitis, and peptic ulcers are sometimes present in CRF and dialysis sufferers. In some research, peptic ulcers and gastroduodenal mucosa lesions had been related to H. pylori an infection [43–47]. Khedmat et al. [6] confirmed that there was no vital distinction within the price of nonerosive gastritis, duodenitis, and gastric ulcer ailments between hemodialysis sufferers and people with regular renal operate. These findings are in accordance with the outcomes of our current meta-analysis, which indicated no statistical variations between dialysis sufferers and regular controls () regarding endoscopic gastritis and ulcerative ailments. Thus plainly dialysis itself will not be a danger issue for the incidence of gastritis or ulcers, though it’s nonetheless essential to carry out endoscopy in dialysis sufferers with gastrointestinal signs. Nonetheless, the above outcomes not often got here from youngsters’s research. Whether or not to suggest higher gastrointestinal examination primarily based on signs requires extra consideration in pediatric dialysis sufferers.

Though within the current meta-analysis we discovered no vital distinction in H. pylori prevalence between dialysis sufferers and management topics, based on some research [21, 48, 49] profitable eradication of H. pylori would result in a major lower in dyspeptic signs, enchancment in higher endoscopic outcomes, and discount in serum gastrin concentrations amongst hemodialysis sufferers. In such sufferers, as a consequence of impaired renal operate and decline within the price of excretion of medicine, the perfect remedy routine ought to emphasize excessive efficacy and few antagonistic results. Seyyedmajidi et al. carried out a randomized managed trial evaluating sequential remedy and normal triple remedy for H. pylori eradication in uraemic and nonuraemic sufferers. The eradication charges didn’t differ with each sequential and normal therapeutic regimens within the sufferers and regular controls. They most well-liked the usual triple remedy as a consequence of its decrease unwanted side effects and complexity [50]. Chang et al. [28] discovered {that a} 7-day triple remedy with a low-dose OAC (omeprazole, amoxicillin, and clarithromycin) routine was efficient and protected for eradication of H. pylori an infection in hemodialysis sufferers, with the consideration that amoxicillin and clarithromycin are primarily eradicated through the renal route. Additional research investigating the impact of eradication of H. pylori on symptom reduction of dialysis sufferers are essential.

When weighing the findings of the current meta-analysis, it’s crucial to notice that these research had been all case-control or cross-sectional research, every carried out at a single middle with a cohort, and the sociodemographic traits of the populations had been unclear. Though we adjusted for potential confounders, heterogeneity nonetheless existed among the many research designs; confounding is an intrinsic limitation of those observational research, so we precluded any evaluation of causality in reported associations. Additionally, variables equivalent to age and gender could also be necessary concerns within the evaluation of danger elements, however right here we had been unable to regulate for them, primarily as a consequence of incomplete knowledge.

5. Conclusion

Within the current meta-analysis there was no proof of a major affiliation between an infection with H. pylori and dialysis therapies for CRF sufferers. With heterogeneity limiting certainty of this affiliation, there’s a want for well-conducted randomized managed trials to additional confirm these findings. In keeping with subgroup evaluation dialysis therapies for greater than 4 12 months seems to have a protecting impact towards H. pylori an infection; mechanistic research of this unfavourable affiliation are wanted to be additional recognized. It’s indeterminable whether or not H. pylori standing would have an effect on period of dialysis in CRF sufferers or whether or not endoscopic abnormalities of dialysis sufferers are associated to H. pylori an infection; additional scientific research investigating the impact of H. pylori an infection on endoscopic findings of dialysis sufferers are essential.

Battle of Pursuits

The authors declare no battle of pursuits.

Authors’ Contribution

Min Gu and Shuping Xiao contributed equally to the work.


This work was supported by Grants from the Nationwide Pure Science Basis of China (nos. 81072032 and 81270476).

Leave a Reply

Your email address will not be published. Required fields are marked *