CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 118 AFRICA Values with p < 0.1 and I² > 50% indicated significant heterogeneity. If there was a limited number of included studies or patients, the heterogeneity of the statistical test may be insensitive. The random-effects model was adopted to analyse the pooled results. We performed sensitivity analysis using the leave-one-out method to identify the sources of heterogeneity. We generated funnel plots to detect publication bias. Results We initially identified 1 892 relevant studies. A total of 184 studies were included after the initial compound search. A total of 143 studies were excluded based on the titles and abstracts. The remaining 41 studies were screened and 33 of them were excluded because they did not meet the inclusion criteria (including one duplicate study21). Ultimately, eight studies22,23,27,29,30,32,34,35 involving 370 participants were included in our meta-analysis. Fig. 1 shows the search strategy. The methodological characteristics of the eight included studies are shown in Table 1. Four studies23,27,34,35 were conducted in China, two 29,30 were conducted in Thailand, one32 in Italy and one22 in Serbia. Seven of the eight studies assessed CACS or AACS via CT imaging, while one study32 used plain lateral abdominal X-ray. Six studies with 262 patients reported an increase in CACS or AACS. Compared with the control group, the results showed that STS was effective in slowing calcification of the coronary or abdominal arteries (SMD –3.24, 95% CI: –5.29 to –1.18, p = 0.002) (Fig. 2). The level of heterogeneity in the six studies was I2 = 98%. Arterial stiffness was measured by PWV in twoRCTs including 104 patients. Among the RCTs, the results demonstrated that the increase in PWV was slower in the STS group compared with the control group (SMD –0.52, 95% CI: –0.92 to –0.13, p = 0.009) (Fig. 3). The level of heterogeneity among the RCTs was I2 = 0%. Six studies with 140 patients reported the effect of intravenous STS treatment on the serum calcium level. STS treatment did not lead to a significant change in serum calcium levels compared with the control group (SMD –0.27, 95% CI: –0.92 to 0.37, p = 0.40) (Fig. 4). The level of heterogeneity was I2 = 85%. Six studies with 90 patients reported the results of intravenous STS treatment on the serum phosphate level. The results showed that there was a significant change in serum phosphate levels after STS treatment (SMD –0.32, 95% CI: –0.62 to –0.03, p = 0.03) (Fig. 5). The heterogeneity was I2 = 0%. Six studies with 142 patients reported the effect of intravenous STS treatment on the serum iPTH level. The pooled results revealed that STS treatment had no effect on the serum levels of iPTH (SMD –0.47, 95% CI: –1.69 to 0.74, p = 0.44) (Fig. 6), and the level of heterogeneity was I2 = 95%. Six studies with 91 patients reported the effect of intravenous STS treatment on serum levels of bicarbonate. The pooled results revealed that STS treatment led to a significant difference in the serum level of bicarbonate (SMD0.67, 95% CI: 0.22 to 1.11, p = 0.003) (Fig. 7), and the level of heterogeneity was I2 = 52%. Six studies with 114 patients reported the effect of intravenous STS treatment on serum levels of hsCRP. The meta-analysis revealed a significant difference in the serum levels of hsCRP after STS treatment (SMD1.61, 95% CI: 0.19 to 3.04, p = 0.03) (Fig. 8), with I2 = 95%. 1 892 citations retrieved from the database search 1 708 excluded after examining the title or abstract due to being non-relevant. 143 articles excluded due to the following: • Review articles • Did not meet inclusion criteria 33 articles excluded due to the following: • Affiliated studies • Unrelated full-text • Undesired outcomes • Duplicated data 8 included articles 41 articles full-text analysis 184 articles retrieved for review Fig. 1. Study selection process. STS Control Std. Mean Difference Std. Mean Difference Study or subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI The increase in Agatston score Adirekkiat 2010 324.5 281 16 455.75 269.25 16 17.4% –0.46 [–1.17, 0.24] Bian 2021 –134.82 20.25 25 51.8 4.66 25 13.8% –12.50 [–15.11, –9.89] Djuric 2019 264 487 26 372 919 26 17.5% –0.14 [–0.67, 0.39] Li 2021 –115.79 10.9 35 –66.68 1.46 35 16.8% –6.25 [–7.41, –5.08] Mao 2018 –317.75 431.29 15 344.25 215.64 15 17.2% –1.89 [–2.77, –1.01] Yu 2016 –216.75 402.12 15 –154.25 157.87 10 17.3% –0.18 [–0.00, 0.62] Subtotal (95% CI) 132 130 100.0% –3.24 [–5.29, –1.18] Heterofeneity: Tau2 = 6.20; Chl2 = 172.01, df = 5 (p < 0.00001); I2 = 97% Test for overall effect: Z = 3.08 (p = 0.002) Total (95% CI) 132 130 100.0% –3.24 [–5.29, –1.18] Heterofeneity: Tau2 = 6.20; Chl2 = 172.01, df = 5 (p < 0.00001); I2 = 97% Test for overall effect: Z = 3.08 (p = 0.002) –20 –10 0 10 20 Favours [STS] Favours [control] Fig. 2. Forest plot of the effect of the increase in CACS or AACS for STS treatment versus the control group in dialysis patients with end-stage renal disease.
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