Rédacteurs : Claude Pernice, Johan Nguyen, Henri Truong

Chronic Kidney Disease

Néphropathies - insuffisance rénale : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture
☆☆ Evidence for effectiveness of acupuncture
Limited evidence for effectiveness of acupuncture
Ø No evidence or insufficient evidence

1.1. Generic Acupuncture

1.1.1. Melo 2020

Melo GAA, Aguiar LL, Silva RA, Pereira FGF, Silva FLBD, Caetano JÁ. Effects of acupuncture in patients with chronic kidney disease: a systematic review. Rev Bras Enferm. 2020;73(4). [209644]. doi

ObjectivesTo analyze the effects of acupuncture techniques in patients with chronic kidney disease.
MethodsA systematic review conducted in six databases, from September to December 2017, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses' criteria. The following descriptors were used: Acupuncture AND Chronic Renal Insufficiency AND Clinical Trial.
ResultsNine studies were selected; the acupuncture techniques used were auriculotherapy, electroacupuncture and acupressure aimed at improving quality of life, fatigue, sleep and clinical variables of the disease. The studies that assessed quality of life, sleep and fatigue presented significant benefits. Studies that assessed quality of life, sleep and fatigue presented significant benefits. There was no statistical significance in the improvement of serum creatinine levels and glomerular filtration rate. Methodological and assessment tools' divergence made impossible meta-analysis.
ConclusionsStudies reinforce the positive effect of acupuncture in improving quality of life, fatigue and sleep in patients.

1.1.2. Kim 2016

Kim KH, Lee MS, Kim TH, Kang JW, Choi TY, Lee JD. Acupuncture and related interventions for symptoms of chronic kidney disease. Cochrane Database Syst Rev. 2016. [186253].

BackgroundPeople living with chronic kidney disease (CKD) experience a range of symptoms and often have complex comorbidities. Many pharmacological interventions for people with CKD have known risks of adverse events. Acupuncture is widely used for symptom management in patients with chronic diseases and in other palliative care settings. However, the safety and efficacy of acupuncture for people with CKD remains largely unknown.
ObjectivesWe aimed to evaluate the benefits and harms of acupuncture, electro-acupuncture, acupressure, moxibustion and other acupuncture-related interventions (alone or combined with other acupuncture-related interventions) for symptoms of CKD. In particular, we planned to compare acupuncture and related interventions with conventional medicine, active non-pharmacological interventions, and routine care for symptoms of CKD.
Methods Search methods: We searched the Cochrane Kidney and Transplant Specialised Register up to 28 January 2016 through contact with the Information Specialist using search terms relevant to this review. We also searched Korean medical databases (including Korean Studies Information, DBPIA, Korea Institute of Science and Technology Information, Research Information Centre for Health Database, KoreaMed, the National Assembly Library) and Chinese databases (including the China Academic Journal). Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs that investigated the effects of acupuncture and related point-stimulation interventions with or without needle penetration that involved six sessions or more in adults with CKD stage 3 to 5, regardless of the language and type of publication. We excluded studies that used herbal medicine or co-interventions administered unequally among the study groups. Data collection and analysis: Two authors independently extracted data and assessed risk of bias. We calculated the mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratio (RR) for dichotomous outcomes. Primary outcomes were changes in pain and depression, and occurrence of serious of adverse events.
Main resultsWe included 24 studies that involved a total of 1787 participants. Studies reported on various types of acupuncture and related interventions including manual acupuncture and acupressure, ear acupressure, transcutaneous electrical acupuncture point stimulation, far-infrared radiation on acupuncture points and indirect moxibustion. CKD stages included pre-dialysis stage 3 or 4 and end-stage kidney disease on either haemodialysis or peritoneal dialysis.None of the included studies assessed pain outcomes, nor formally addressed occurrence of serious adverse events, although three studies reported three participant deaths and three hospitalisations as reasons for attrition. Three studies reported minor acupuncture-related harms; the remainder did not report if those events occurred.All studies were assessed at high or unclear risk of bias in terms of allocation concealment. Seventeen studies reported outcomes measured for only two months.There was very low quality of evidence that compared with routine care, manual acupressure reduced scores of the Beck Depression Inventory score (scale from 0 to 63) (3 studies, 128 participants: MD -4.29, 95% CI -7.48 to -1.11, I(2) = 0%), the revised Piper Fatigue Scale (scale from 0 to 10) (3 studies, 128 participants: MD -1.19, 95% CI -1.77 to -0.60, I(2) = 0%), and the Pittsburgh Sleep Quality Index (scale from 0 to 21) (4 studies, 180 participants: MD -2.46, 95% CI -4.23 to -0.69, I(2) = 50%).We were unable to perform further meta-analyses because of the paucity of data and problems with clinical heterogeneity, such as different interventions, comparisons and timing of outcome measurements.
Authors' conclusions There was very low quality of evidence of the short-term effects of manual acupressure as an adjuvant intervention for fatigue, depression, sleep disturbance and uraemic pruritus in patients undergoing regular haemodialysis. The paucity of evidence indicates that there is little evidence of the effects of other types of acupuncture for other outcomes, including pain, in patients with other stages of CKD. Overall high or unclear risk of bias distorts the validity of the reported benefit of acupuncture and makes the estimated effects uncertain. The incomplete reporting of acupuncture-related harm does not permit us to assess the safety of acupuncture and related interventions. Future studies should investigate the effects and safety of acupuncture for pain and other common symptoms in patients with CKD and those undergoing dialysis.

1.2. Special Acupuncture Techniques

1.2.1. Moxibustion

1.2.1.1. Zhou 2020

Zhou X, Wu Q, Wang Y, Ren Q, Zhu W, Yao Z, Chen J. Moxibustion as an Adjuvant Therapy for Chronic Kidney Disease: A Systematic Review and Meta-Analysis of 23 Randomized Controlled Trials. Evid Based Complement Alternat Med. 2020. [214007]. doi

ObjectiveThis systematic review aims to investigate the efficacy and safety of moxibustion for chronic kidney disease (CKD).
MethodsNine databases were searched to identify relevant evidence up to March 8, 2020. Randomized controlled trials (RCTs) that tested moxibustion + basic treatments versus basic treatments alone for patients with CKD and reported, at least, one of the outcomes of interest were included. In the meta-analyses, the mean differences (MDs) and 95% confidence intervals (CIs) were used to measure the effect size.
ResultsTwenty-three RCTs (n = 1571) with a moderate to high risk of bias were included. The pooled estimates showed that compared with the controls, patients after moxibustion had a significant reduction in serum creatinine (MD -17.34 μmol/L, 95% CI -28.44 to -6.23; I 2 = 87%), 24-hour urine protein excretion (MD -0.75 g/h, 95% CI -1.07 to -0.42; I 2 = 84%), and blood urea nitrogen (MD -0.63 mmol/L, 95% CI -1.09 to -0.18; I 2 = 37%) and a significant improvement in the quality of life (MD 10.18, 95% CI 3.67 to 16.69; I 2 = 57%). Moxibustion did not show a significant effect on the estimated glomerular filtration rate (eGFR), creatinine clearance, or hemoglobin. The subgroup analyses showed that a longer course of moxibustion (>8 weeks) and indirect moxibustion had a greater effect on reducing serum creatinine. The effect of moxibustion on blood urea nitrogen changed to be nonsignificant after excluding RCTs with a high risk of bias (MD -0.96 mmol/L, 95% CI -2.96 to 1.03). Only one adverse event of burn was reported.
ConclusionsThis systematic review suggests that, as an adjuvant therapy, moxibustion may improve serum creatinine, urinary protein excretion, blood urea nitrogen, and quality of life in patients with CKD. Moxibustion may not have effects on eGFR, creatinine clearance, or hemoglobin. The quality of evidence is weakened by the limitations of risk of bias, heterogeneity, and imprecision.

1.2.2. Acupoint injection

1.2.2.1. Yang 2020

Yang T, Zhao J, Guo Q, Wang Y, Si G. Acupoint injection treatment for non-dialysis dependent chronic kidney disease: A meta-analysis of randomized controlled trials. Medicine (Baltimore). 2020;99(51). [217077]. doi

AimTo analyze the effects of acupoint injection in the treatment of non-dialysis dependent chronic kidney disease through a systematic review with meta-analysis.
MethodsThis systematic review with meta-analysis was conducted following the recommendations of the declaration of PRISMA. Full-text literature of randomized controlled trial of acupoint injection therapy for non-dialysis chronic kidney disease was searched in PubMed, Embase, Cochrane Library, China National Knowledge Internet, the Chinese Scientific Journal Database, the Wanfang Database, China Biology Medicine database. The efficacy and safety of acupoint injection for non-dialysis chronic kidney disease were evaluated.
Results Seventeen studies containing 1414 patients met the criteria. The results shows that acupoint injection combined with basic treatment can significantly improve the levels of Ccr (WMD = 4.81; 95% CI:2.54 to 7.08) and Hb (WMD = 4.56; 95% CI:1.72 to 7.39), reduce the levels of BUN (WMD = -0.90; 95% CI: -1.26 to -0.54)and Scr (WMD = -7.66; 95% CI: -12.39 to -2.93), and improve the effective rate (OR = 3.12; 95% CI: 2.29 to 4.26).
ConclusionOur current analysis showed that combined acupoint injection therapy can reduce the levels of BUN and Scr, and increase Ccr and Hb in non-dialysis CKD patients. However, the existing evidence is still insufficient due to the high risk of included trial bias, and future research needs to improve methodological quality.

1.3. Special Clinical Forms

1.3.1. Uremic Pruritus

1.3.2. Diabetic Kidney Disease

Zhao Qing. [Meta-analysis of acupuncture as an adjuvant treatment for diabetic kidney disease]. Modern Chinese Clinical Medicine. 2020. [212926].

ObjectiveTo make a systematic evaluation of clinical efficacy of acupuncture as an adjuvant treatment for diabetic nephropathy.
Methods Databases including PubMed, EMbase, BMJ, CNKI, Wang fang and VIP were searched. Two researchers independently screened the literature and extracted the data, and then evaluated the quality of the literature, and last performed a meta-analysis using RevMan 5. 3.
Results A total of 8 trials involving 491 patients were included. Compared with the single treatment group just as the Western medicine or the traditional Chinese medicine, acupuncture treatment reduced UAE[SMD=-2. 49, 95%CI-4. 11 to 0. 86, P=0. 003;I~2=97%;5 trials], Scr[MD=-15. 44, 95%CI-26. 55 to-4. 33, P=0. 006;I~2=90%;5 trials], BUN [MD=-1. 83, 95%CI-2. 97 to-0. 70, P=0. 002;I~2=93%;4 trials] and TG[MD=-0. 69, 95%CI-1. 23 to-0. 15, P=0. 01;I~2=87%;4 trials], and improved clinical total effective rate[OR=3. 89, 95%CI 2. 18 to 6. 93, P<0. 000 01;I~2=0%;7 trials].
Conclusions The treatment of acupuncture has a favorable therapeutic efficacy for DKD. It can significantly reduce UAE and blood lipid and can improve renal function and effectiveness of clinical treatment of DKD. Importance should be attached to the acupoints of Shenshu (BL 23)

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation, (or lack of evidence)

2.1. Kidney Health Australia (KHA, Australia) 2015 ⊕ (polykystose rénale)

Savige J, Tunnicliffe DJ, Gopala K. Rangan GK. KHA-CARI Autosomal Dominant Kidney Disease Guideline: Management of Chronic Pain. Seminars in Nephrology. 2015;35(6):607-611. [196849].

We recommend that patients be involved in the management of their pain, non-pharmacological treatments be emphasized in the first instance (1D) [Acupuncture].