The efficacy and safety of Helicobacter pylori eradication regimens in patients receiving hemodialysis: a systematic review and network meta-analysis.

INTRODUCTION: Helicobacter pylori eradication is clinically important in patients on hemodialysis (HD), who are at risk for serious gastrointestinal complications. However, altered drug metabolism and antibiotic resistance in patients on HD complicate H. pylori eradication. This study aimed to perform a network meta-analysis to synthesize existing evidence on the efficacy and safety of H. pylori eradication regimens in patients on HD. METHODS: We searched MEDLINE, the Cochrane Library, EMBASE, Ichushi-web, ICTRP, and ClinicalTrials.gov. Two reviewers independently selected randomized controlled trials that evaluated H. pylori eradication therapy in patients undergoing HD. We performed a frequentist random effects network meta-analysis. The primary outcome was eradication rate, and the secondary outcomes were treatment completion rates and all adverse events. We used CINeMA to assess the confidence in the evidence. The study protocol was registered at OSF (https://osf.io/gn978/). RESULTS: Ten trials involving 481 patients were included in the analysis. Seven eradication regimens were compared: six concomitant and one sequential regimen. Relative to standard-dose proton pump inhibitor/clarithromycin/amoxicillin regimens (PAC), the evidence is very uncertain about the effect of the proton pump inhibitor/clarithromycin regimen on the eradication rate (odds ratio, 0.11; 95% confidence interval, 0.01-1.07). For reduced-dose PAC (in which clarithromycin or amoxicillin is dose-reduced), alternative regimens (with azithromycin, metronidazole, or levofloxacin), and sequential regimens, the estimates were too imprecise to determine whether a difference from PAC exists (low certainty). Treatment completion rates were generally favorable (83-100%), and adverse events were most frequent with standard-dose PAC (45%). CONCLUSIONS: Reduced-dose PAC and alternative and sequential regimens may be considered for H. pylori eradication in patients on HD.