Effects of vitamin E-coated dialysis membranes on anemia, nutrition and dyslipidemia status in hemodialysis patients: a meta-analysis

Figures & data

Figure 1. Flow diagram of study selection.

Table 1. Characteristic of included studies.

Author, year, country	Study design	No. of patients	Mean age (years)	Gender (M/F)	Dialytic age (years)	Study duration (months)	Intervention	Results
Andrulli, 2010, Italy22	Not blind, Parallel	E: 10^a	E: 67 (58–76)^b	E: 5/5	E: 3.5(2.0–9.7)^b	8	E: Vit E-coated PSM dialyzer	No effect on HB level and weekly EPO does
		C: 10	C: 72 (59–74)^b	C: 5/5	C: 3.3(1.8–6.1)^b		C: PSM dialyzer
Al-Jondeby, 2003,  Saudi Arabia	Not blind, Crossover	E: 34	E: 61.52	E: 20/14	E: 62.11 months	1	E: Vit E-bonded dialyzers	No effect on HB level
		C: 41	C: 51.97	C: 22/19	C: 63.17 months		C: PSM dialyzer
Baragetti, 2006, Italy21	Not blind, Parallel	E: 8	E: 68.25 ± 1.76	E: 4/4	E: 53 ± 17.2 months	42 weeks	E: Vit E-coated dialyzer	No effect on EPO resistance
		C: 8	C: 68 ± 1.77	C: 5/3	C: 50 ± 15.8 months		C: CLSM dialyzer
Bufano, 2004, Italy	Not blind, Parallel	E: 16	E: 59.2 ± 6.8	NR	E: 29.9 ± 7.8 months	6	E: Vit E-coated dialyzer	Decrease endothelial cells damage
		C: 16	C: 58.0 ± 7.3		C: 30.4 ± 9.6 months		C: CLSM dialyzer
Clermont, 2001, France23	Not blind, Crossover	E: 6	61.6 ± 4.0	11/5	NR	1	E: Vit E-coated dialyzer	No effect on HB level
		C: 10					C: Synthetic hollow fiber dialyzer
Kirmizis, 2011, Greece24	Not blind, Parallel	E: 37^c	E: 55.0 ± 16.0	E: 19/16	E: 84 ± 58 months	6	E: Vit E-coated dialyzer	No effect on dyslipidemia and malnutrition
		C: 25	C: 62.0 ± 13.0	C: 12/13	C: 65 ± 41 months		C: CLSM, PSM, hemophage membrane dialyzer
Kobayashi, 2003,  Japan13	Not blind, Parallel	E: 17	E: 60.9 ± 13.0	E: 10/7	E: 4.4 ± 2.6	12	E: Vit E-bonded cellulose dialyzer	Decrease atherosclerosis and EPO does
		C: 17	C: 63.2 ± 10.7	C: 9/8	C: 4.4 ± 2.7		C: CLSM dialyzer
Lines, 2014,  United Kingdom16	Not blind, Parallel	E: 123^d1	E: 62.6 ± 1.5	E: 76/47	E: 3.2(1.2–6.6)	12	E: Vit E-coated PSM dialyzer	No effect on EPO resistance
		C: 137^d2	C: 64.0 ± 1.3	C: 80/57	C: 3.9(1.8–7.6)		C: PSM dialyzer
Mandolfo, 2012, Italy14	Not blind, Crossover	E: 8	72.3 ± 8.9	NR	45.5 ± 40.8 months	6	E: Vit E-bonded PSM dialyzer	Decrease EPO resistance
		C: 8					C: PSM dialyzer
Morimoto, 2005, Japan25	Not blind, Crossover	E: 16	E: 69.4 ± 10.6	E: 8/8	E: 77.8 ± 65.1 months	6	E: Vit E-coated PSM dialyzer	Decrease weekly EPO does
		C: 15	C: 69.0 ± 12.2	C: 7/8	C: 73.9 ± 58.3 months		C: PSM dialyzer
Nakamura, 2003, Japan26	Not blind, Parallel	E: 7	E: 54.0 ± 5.2	E: 5/2	E: 5.0 ± 2.2	10 weeks	E: Vit E-coated dialyzer	Decrease atherosclerosis
		C: 12	C: 54.5 ± 5.0	C: 8/4	C: 4.5 ± 2.0		C: CLSM dialyzer
Panichi, 2011, Italy	Single blind, Crossover	E: 31	E: 68 ± 13	E: 16/15	48 ± 27 months	6	E: Vit E-coated PSM dialyzer	Decrease weekly EPO does
		C: 31	C: 63 ± 11	C: 18/13			C: PSM dialyzer
Sanaka, 2013, Japan15	Not blind, Parallel	E1: 95^e1	E1: 64.6 ± 11.4	NR	E1: 80.4 ± 67.3 months	12	E: Vit E-coated PSM dialyzer	No effect on EPO resistance
		C1: 99^e2	C1: 61.5 ± 12.2		C1: 73.5 ± 74.1 months		C: PSM dialyzer
		E2: 56^e3	E2: 57.4 ± 13.7		E2: 92.3 ± 79.8 months
		C2: 55^e4	C2: 62.8 ± 12.5		C2: 84.1 ± 72.5 months
Usberti, 2002, Italy27	Not blind, Parallel	E: 9	E: 63.0 ± 11.0	NR	E: 90 ± 75 months	3	E: Vit E-coated dialyzer	Improve anemia
		C: 18	C: 64.0 ± 15.0		C: 99 ± 86 months		C: CLSM and PSM dialyzer

Notes: PSM: polysulfone membrane; CLSM: cellulose membrane; Vit: Vitamin; NR: not reported; E: vitamin E-coated dialyzer group; C: conventional dialyzer group; EPO: erythropoietin; HB: hemoglobin.

^aNine patients in vitamin E-coated dialyzer treatment group completed the study.

^bValues were reported as median (range).

^cThirty five patients in vitamin E-coated dialyzer treatment group completed the study.

^d1Hundered and four patients in vitamin E-coated dialyzer treatment group completed the study.

^d2Hundred and sixteen patients in control group completed the study.

^e1Seventy four patients in vitamin E-coated dialyzer treatment group completed the study (10 ≤ Hb ≤ 11).

^e2Sixty seven patients in control group completed the study (10 ≤ Hb ≤ 11).

^e3Fourty patients in vitamin E-coated dialyzer treatment group completed the study (11 ≤ Hb ≤ 12).

^e4Thirty two patients in control group completed the study (11 ≤ Hb ≤ 12).

Figure 2. Risk of bias graph and bias summary: review authors’ judgements about each risk of bias item presented as percentages across all included studies and review authors’ judgements about each risk of bias item for each included study.

Figure 3. Forest plot of studies comparing the effect of vitamin E-coated dialyzer versus conventional dialyzer on HB level in hemodialysis patients.

Figure 4. Forest plot of studies comparing the effect of vitamin E-coated dialyzer versus conventional dialyzer on EPO dose and EPO resistance index in hemodialysis patients.

Figure 5. Forest plot of studies comparing the effect of vitamin E-coated dialyzer versus conventional dialyzer on serum Alb, IMT of the carotid artery and Kt/V levels in hemodialysis patients.

Figure 6. Forest plot of studies comparing the effect of vitamin E-coated dialyzer versus conventional dialyzer on lipid parameters in hemodialysis patients.

Table 2. Summary effect of vitamin E-coated dialyzer on maintenance hemodialysis patients.

					Assessment of	Publication bias
Outcome variables	No. studies	No. patients	Mean net change (95% CI)	p-Value	heterogeneity I^2 index(%)	Q-statistic p-Value	Funnel plots
Anemia parameters
EPO (total)	6	372	−0.11 (−0.32, 0.09)	0.28	27	0.23	Symmetric
EPO (study duration <6 months)	1	16	0.85 (−0.22, 1.92)	0.12	–	–	–
EPO (study duration = 6 months)	3	109	−0.12 (−0.50, 0.25)	0.53	0	0.77	–
EPO (study duration >6 months)	2	247	−0.16 (−0.41, 0.09)	0.21	54	0.11	–
EPO (VEM dialyzer vs. BCM dialyzer)1	5	338	−0.04 (−0.26, 0.17)	0.69	0	0.64	–
EPO (VEM dialyzer vs. BICM dialyzer)2	1	34	−0.87 (−1.57, −0.16)	0.02	–	–	–
HB (total)	6	354	−0.03 (−0.18, 0.13)	0.74	50	0.06	Symmetric
HB (VEM dialyzer vs. BCM dialyzer)1	5	338	−0.02 (−0.17, 0.14)	0.85	53	0.06	–
HB (VEM dialyzer vs. BICM dialyzer)2	1	16	−0.8 (−2.13, 0.53)	0.24	–	–	–
HB (study duration <6 months)	1	16	−0.30 (−0.60, 0.00)	0.05	–	–	–
HB (study duration = 6 months)	3	109	0.36 (0.07, 0.65)	0.01	0	0.86	–
HB (study duration >6 months)	3	229	−0.12 (−0.37, 0.12)	0.32	0	0.60	–
EPO resistance index	3	291	−0.24 (−0.47, −0.01)	0.04	35%	0.21	Asymmetric
Nutritional marker
ALB (total)	4	108	−0.64 (−1.62, 0.34)	0.2	78	0.004	Asymmetric
Lipidemia parameters
Tchol	3	111	−0.07 (−0.45, 0.31)	0.71	0	0.46	Symmetric
TG	2	79	−2.77 (−32.42, 26.87)	0.85	0	0.95	Symmetric
HDL	3	111	0.24 (−0.14, 0.62)	0.22	0	0.56	Symmetric
LDL	3	111	0.00 (−0.38, 0.37)	0.98	0	0.74	Symmetric
Atherosclerosis parameters
IMT	2	53	−0.09 (−0.2, 0.01)	0.09	0	0.58	Asymmetric
Dialysis adequacy markers
Kt/V	4	79	−0.07 (−0.14, 0.00)	0.06	0	0.85	Asymmetric

Notes: EPO: erythropoietin, HB: hemoglobin, Alb: albumin, Tchol: total cholesterol, TG: triglyceride, HDL: high density lipoprotein, LDL: low density lipoprotein, IMT: intima–media thickness, Kt/V: fractional clearance of urea.

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