Michele L. HalesMichele L. Hales

University of AlbertaUniversity of Alberta

Edmonton, AB CANADAEdmonton, AB CANADA

Dubai, U.A.E.Dubai, U.A.E.October 2October 2ndnd & 3 & 3rdrd, 2003, 2003

Systematic Reviews,Systematic Reviews,

The Cochrane The Cochrane CollaborationCollaboration

The Cochrane The Cochrane CollaborationCollaboration

"It is surely a great criticism of our "It is surely a great criticism of our profession that we have not organised profession that we have not organised a critical summary, by specialty or a critical summary, by specialty or subspecialty, adapted periodically, of subspecialty, adapted periodically, of all relevant randomised controlled all relevant randomised controlled trials"trials". .

-- Archie Cochrane, 1979-- Archie Cochrane, 1979

The Collaboration is being The Collaboration is being built on a set of eight built on a set of eight values:values:1.1. CollaborationCollaboration2.2. Building on the enthusiasm of Building on the enthusiasm of

individualsindividuals3.3. Avoiding duplicationAvoiding duplication4.4. Minimizing biasMinimizing bias5.5. Keeping up to dateKeeping up to date6.6. Ensuring relevanceEnsuring relevance7.7. Ensuring accessEnsuring access8.8. Continually improving the quality of Continually improving the quality of

workworkM. Haugh and D. Fouque. Evidence-based nephrology. Nephrol Dial Transplant (1999) 14 [Suppl 3]: 38-41

The The Cochrane CollaborationCochrane Collaboration is an is an international network of health care international network of health care professionals, researchers and professionals, researchers and consumers who are interested in consumers who are interested in developing and maintaining developing and maintaining comprehensive, regularly updated comprehensive, regularly updated critical reviews of evidence from critical reviews of evidence from randomised clinical trials relevant to randomised clinical trials relevant to their specialty and interests.their specialty and interests.

Brief HistoryBrief History The first systematic reviews were in The first systematic reviews were in

the field of Pregnancy and Childbirth. the field of Pregnancy and Childbirth.

Increased interest from professional Increased interest from professional groups, health managers, and groups, health managers, and government organisations in extending government organisations in extending the scope of systematic reviews. the scope of systematic reviews.

The The Cochrane Database of Systematic Cochrane Database of Systematic ReviewsReviews is now published quarterly in is now published quarterly in the electronic journal the electronic journal The Cochrane The Cochrane LibraryLibrary. .

Cochrane CentresCochrane Centres Cochrane Centres have been established in Cochrane Centres have been established in

a number of countries world-wide, funded a number of countries world-wide, funded by both government and charitable by both government and charitable sources.sources.

Responsible for maintaining registers of Responsible for maintaining registers of known randomised controlled trials, known randomised controlled trials, complete systematic reviews as well as complete systematic reviews as well as current and potential contributors to the current and potential contributors to the Collaboration.Collaboration.

Provide advice and training to those who Provide advice and training to those who contribute to the Collaboration . contribute to the Collaboration .

The Cochrane Renal Group The Cochrane Renal Group (CRG)(CRG)

The Cochrane Renal Group (CRG) began The Cochrane Renal Group (CRG) began March 1, 1997.March 1, 1997.

The Cochrane Renal Group (CRG) is one The Cochrane Renal Group (CRG) is one of 50 of 50 Cochrane CollaborationCochrane Collaboration review review groups around the world and consists of groups around the world and consists of individuals who share a common interest individuals who share a common interest in renal disease. Members of the group in renal disease. Members of the group include reviewers, handsearchers, include reviewers, handsearchers, referees, consumers, government as well referees, consumers, government as well as the editorial team. as the editorial team.

What is a systematic What is a systematic review?review?

A reviewer must:A reviewer must:1.1. identify an intervention for a specific disease, identify an intervention for a specific disease,

and ask whether or not this intervention works. and ask whether or not this intervention works.

It’s accomplished by:It’s accomplished by:1.1. locating, reviewing and assessing evidence locating, reviewing and assessing evidence

from as many relevant scientific studies as from as many relevant scientific studies as possible. possible.

2.2. summarising the conclusion with respect to its summarising the conclusion with respect to its effectivenesseffectiveness

3.3. providing the summary as a unique collation of providing the summary as a unique collation of the known evidence on a given topic. the known evidence on a given topic.

At this point, the primary studies for any At this point, the primary studies for any intervention are made available for others to intervention are made available for others to review.review.

Validity Guide of the SRValidity Guide of the SR

1.1. Is this a systematic review of Is this a systematic review of randomised trials?randomised trials?

2.2. Does this systematic review have a Does this systematic review have a “methods” section that describes:“methods” section that describes:

Finding and including all relevant trialsFinding and including all relevant trials How the validity of the individual How the validity of the individual

studies was assessed?studies was assessed?

3.3. Were the results consistent from Were the results consistent from study to study?study to study?

Importance of SR Importance of SR Validity Results Validity Results

1.1. What is the magitude of the treatment effect?What is the magitude of the treatment effect?2.2. How precise is the treatment effect?How precise is the treatment effect?

Are the valid results of this SR Are the valid results of this SR applicable to our Patient?applicable to our Patient?1. Is our patient so different from those in the

study that its results?2. How precise is the treatment effect?3. What are our patient’s potential benefits and

harms from the therapy?4. What are our patient’s values and preferences

for both the outcome we are trying to prevent and the side-effects we may cause?

Renal ReviewsRenal Reviews

Responsibilities include:Responsibilities include: Identify all trials concerning renal Identify all trials concerning renal

diseasesdiseases Assess the trials for relevance and Assess the trials for relevance and

qualityquality Assemble and analyse the trial dataAssemble and analyse the trial data Prepare structured reports for inclusion Prepare structured reports for inclusion

in the Cochrane Database of Systematic in the Cochrane Database of Systematic ReviewsReviews

CRG’s FocusCRG’s Focus

The Cochrane Renal Group's focus includes The Cochrane Renal Group's focus includes the following major areas of renal disease:the following major areas of renal disease:

Acute renal failure Acute renal failure Chronic renal failure Chronic renal failure Dialysis: both peritoneal and haemodialysis Dialysis: both peritoneal and haemodialysis Renal transplantation Renal transplantation Renovascular hypertension Renovascular hypertension Glomerular diseases Glomerular diseases Urinary tract infections Urinary tract infections Nephrolithiasis Nephrolithiasis

Areas of High PriorityAreas of High Priority

Renal TransplantationRenal Transplantation Tacrolimus for renal transplant recipientsTacrolimus for renal transplant recipients Antilymphocyte preparations for renal transplant recipientsAntilymphocyte preparations for renal transplant recipients IL-21 receptor blockers for renal transplant recipientsIL-21 receptor blockers for renal transplant recipients Sirolimus for renal transplant recipientsSirolimus for renal transplant recipients

DialysisDialysis Interventions to prevent peritonitis & exit site infections in Interventions to prevent peritonitis & exit site infections in

peritoneal dialysisperitoneal dialysis Treatment for dialysis-related hypotensionTreatment for dialysis-related hypotension

General NephrologyGeneral Nephrology Corticosteroids for minimal change nephropathy in adultsCorticosteroids for minimal change nephropathy in adults Interventions to prevent contrast-induced nephropathyInterventions to prevent contrast-induced nephropathy Interventions to reduce infection risk in nephrotic syndromeInterventions to reduce infection risk in nephrotic syndrome Interventions to reduce thrombosis risk in nephrotic Interventions to reduce thrombosis risk in nephrotic

syndromesyndrome

Trials in NephrologyTrials in Nephrology

Published Trials (4100)Published Trials (4100) Ongoing Trials (57)Ongoing Trials (57)

Current TrialsCurrent Trials

Acute Renal Failure Acute Renal Failure (1)(1) Diabetic Nephropathy Diabetic Nephropathy (4)(4) Dialysis Dialysis (17)(17) General Nephrology General Nephrology (14)(14) Transplantation Transplantation (17)(17) Urinary Tract Infection Urinary Tract Infection (3)(3)

Current TrialsCurrent TrialsAcute Renal Failure (1)Acute Renal Failure (1)

1)1) Effects of different doses in continuous veno-Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial.renal failure: a prospective randomised trial.

Diabetic Nephropathy (4)Diabetic Nephropathy (4)1)1) Dual blockade of the renin-angiotensin system Dual blockade of the renin-angiotensin system

in type 1 patients with diabetic nephropathyin type 1 patients with diabetic nephropathy2)2) Effect of dietary protein restriction on Effect of dietary protein restriction on

prognosis in patients with diabetic prognosis in patients with diabetic nephropathynephropathy

3)3) The role of angiotensin II receptor blockers in The role of angiotensin II receptor blockers in preventing the progression of renal disease in preventing the progression of renal disease in patients with type 2 diabetes.patients with type 2 diabetes.

4)4) Dual blockade of the renin-angiotensin system Dual blockade of the renin-angiotensin system versus maximal recommended dose of ACE versus maximal recommended dose of ACE inhibition in diabetic nephropathy.inhibition in diabetic nephropathy.

Current Trials Cont’dCurrent Trials Cont’dDialysis (17)Dialysis (17)

1)1) Transferrin saturation versus reticulocyte Transferrin saturation versus reticulocyte hemoglobin content for iron deficiency in hemoglobin content for iron deficiency in Japanese hemodialysis patients.Japanese hemodialysis patients.

2)2) Creatine monohydrate treatment alleviates Creatine monohydrate treatment alleviates muscle cramps associated with haemodialysis.muscle cramps associated with haemodialysis.

3)3) Effect of dialysis dose and membrane flux in Effect of dialysis dose and membrane flux in maintenance hemodialysis.maintenance hemodialysis.

4)4) A controlled, prospective study of the effects A controlled, prospective study of the effects of atorvastatin on proteinuria and progression of atorvastatin on proteinuria and progression of kidney disease.of kidney disease.

5)5) Effects of long and short hemodialysis on Effects of long and short hemodialysis on endothelial function: A short-term study.endothelial function: A short-term study.

6)6) Effects of raloxifene on bone metabolism and Effects of raloxifene on bone metabolism and serum lipids in postmenopausal women on serum lipids in postmenopausal women on chronic hemodialysis.chronic hemodialysis.

Current Trials Cont’dCurrent Trials Cont’d

General Nephrology (14)General Nephrology (14)1)1) Reduction of proteinuria; combined effects of Reduction of proteinuria; combined effects of

receptor blockade and low dose angiotensin-receptor blockade and low dose angiotensin-converting enzyme inhibition. [see comments.]converting enzyme inhibition. [see comments.]

2)2) Renoprotective effect of small doses of losartan Renoprotective effect of small doses of losartan and enalapril in patients with primary and enalapril in patients with primary glomerulonephritis. Short-term observation.glomerulonephritis. Short-term observation.

3)3) Effects of combined ACE inhibitor and Effects of combined ACE inhibitor and angiotensin II antagonist treatment in human angiotensin II antagonist treatment in human chronic nephropathies.chronic nephropathies.

4)4) Carvedilol increases two-year survival in Carvedilol increases two-year survival in dialysis patients with dilated cardiomyopathy: a dialysis patients with dilated cardiomyopathy: a prospective, placebo-controlled trial.prospective, placebo-controlled trial.

5)5) Antihypertensive treatment with and without Antihypertensive treatment with and without benazepril in patients with chronic renal benazepril in patients with chronic renal insufficiency: a US economic evaluation.insufficiency: a US economic evaluation.

The Cochrane LibraryThe Cochrane Library

It is a one of a kind source of reliable, up to It is a one of a kind source of reliable, up to date information on the effects of interventions date information on the effects of interventions in health care. Today’s healthcare needs to in health care. Today’s healthcare needs to include the best information on the include the best information on the effectiveness of each intervention being effectiveness of each intervention being accessible to practitioners, patients, and policy accessible to practitioners, patients, and policy makers. This is “evidence-based medicine.”makers. This is “evidence-based medicine.”

The library is designed to provide information The library is designed to provide information and evidence to support decisions taken in and evidence to support decisions taken in health care and to inform those receiving care.health care and to inform those receiving care.

Cochrane LibraryCochrane Library

The Library includes:The Library includes: Full text, including graphs, of the Full text, including graphs, of the

original systematic revieworiginal systematic review Quality assessed informationQuality assessed information Critical appraisals of high-quality Critical appraisals of high-quality

reviews published elsewherereviews published elsewhere A number of very useful accompanying A number of very useful accompanying

databasesdatabases

Searches – Library Searches – Library DatabaseDatabase

Search by specific topicSearch by specific topic Combine words or phrases to modify Combine words or phrases to modify

the meaning of a searchthe meaning of a search Searches can be refined by selecting Searches can be refined by selecting

date ranges, document status, or by date ranges, document status, or by titles or authors onlytitles or authors only

The history screen grabs each search The history screen grabs each search for future retrieval or to combine with for future retrieval or to combine with new search termsnew search terms

MeSH ThesaurusMeSH Thesaurus The library provides a MeSH search The library provides a MeSH search

facility as an added search aid facility as an added search aid The MeSH thesaurus is published by the The MeSH thesaurus is published by the

NLMNLM Has a vocabulary of 15,000 terms for Has a vocabulary of 15,000 terms for

precise description of the medical precise description of the medical documents contentdocuments content

Terms are arranged as a ‘tree structure’ Terms are arranged as a ‘tree structure’ which links related terms.which links related terms.

Terms can be further defined by the Terms can be further defined by the addition of qualifiersaddition of qualifiers

The Renal Health LibraryThe Renal Health Library

It contains:It contains: relevant systematic reviews on kidney disease relevant systematic reviews on kidney disease

from the from the Cochrane Database of Systematic Cochrane Database of Systematic ReviewsReviews

references to over 4000 randomised controlled references to over 4000 randomised controlled trials in kidney disease from the Cochrane trials in kidney disease from the Cochrane Renal Group's Renal Group's Renal Trials RegisterRenal Trials Register, including , including 650 abstracts from conference proceedings 650 abstracts from conference proceedings

over 50 reports of ongoing randomised over 50 reports of ongoing randomised controlled trials controlled trials

information about the Cochrane Collaboration, information about the Cochrane Collaboration, the Cochrane Renal Group and the systematic the Cochrane Renal Group and the systematic review process review process

Renal Health Library CDRenal Health Library CD

May 2003 (1May 2003 (1stst Issue) Issue) Contains over 4000 randomised Contains over 4000 randomised

controlled trials, including ongoing controlled trials, including ongoing trials, with links to abstracts on trials, with links to abstracts on PubMed and 36 full-text reviews in PubMed and 36 full-text reviews in nephrology. nephrology.

Contact InformationContact Information

Cochrane Renal GroupCochrane Renal GroupCentre for Kidney ResearchCentre for Kidney Research

The Children’s Hospital at WestmeadThe Children’s Hospital at WestmeadNSW 2045 AustraliaNSW 2045 Australia

tel: +61 2 9845 1292 tel: +61 2 9845 1292 fax: +61 2 9845 3038 fax: +61 2 9845 3038

e-mail: crg@chw.edu.au e-mail: crg@chw.edu.au website: www.cochrane-renal.orgwebsite: www.cochrane-renal.org