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Table 4 GRADE evidence profile for effectiveness of influenza vaccination in patients with end-stage renal disease

From: Influenza vaccination in patients with end-stage renal disease: systematic review and assessment of quality of evidence related to vaccine efficacy, effectiveness, and safety

Quality assessment No of patients Effect Quality Importance
No of studies Design Risk of bias Inconsistency Indirectness Imprecision Other considerations Vaccination against influenza Control Relative (95% CI) Absolute   
All-cause mortality
4 Observational studies Serious1 No serious inconsistency No serious indirectness No serious imprecision None 1,798/8,759 (20.5%)2 RR 0.68 (0.61–0.76)3 66 fewer per 1,000 (from 49 fewer to 80 fewer) ΟΟΟ VERY LOW CRITICAL
  10% 32 fewer per 1,000 (from 24 fewer to 39 fewer)
  40% 128 fewer per 1,000 (from 96 fewer to 156 fewer)
Cardiac death
1 Observational studies Serious4 No serious inconsistency No serious indirectness No serious imprecision None 5% RR 0.84 (0.71–0.98)5 8 fewer per 1,000 (from 1 fewer to 15 fewer) ΟΟΟ VERY LOW CRITICAL
  10% 16 fewer per 1,000 (from 2 fewer to 29 fewer)
  20% 32 fewer per 1,000 (from 4 fewer to 58 fewer)
Infectious death
1 Observational studies Serious4 No serious inconsistency No serious indirectness No serious imprecision None 5% RR 0.83 (0.65–1.05)5 9 fewer per 1,000 (from 18 fewer to 2 more) ΟΟΟ VERY LOW CRITICAL
  10% 17 fewer per 1,000 (from 35 fewer to 5 more)
  20% 34 fewer per 1,000 (from 70 fewer to 10 more)
All-cause hospitalization
2 Observational studies Serious1 No serious inconsistency No serious indirectness No serious imprecision None 1,688/1,888 (89.4%)6 RR 0.88 (0.74–1.04)7 107 fewer per 1,000 (from 232 fewer to 36 more) ΟΟΟ VERY LOW CRITICAL
  20% 24 fewer per 1,000 (from 52 fewer to 8 more)
  40% 48 fewer per 1,000 (from 104 fewer to 16 more)
Influenza/pneumonia hospitalization
4 Observational studies Serious8 No serious inconsistency No serious indirectness No serious imprecision None 445/2,584 (17.2%) RR 0.86 (0.8–0.93)3 24 fewer per 1,000 (from 12 fewer to 34 fewer) ΟΟΟ VERY LOW CRITICAL
  5% 7 fewer per 1,000 (from 3 fewer to 10 fewer)
  30% 42 fewer per 1,000 (from 21 fewer to 60 fewer)
Hospitalization due to bacteremia, viremia or septicemia
1 Observational studies Serious4 No serious inconsistency No serious indirectness No serious imprecision None 5% RR 0.73 (0.32–1.68)5 13 fewer per 1,000 (from 34 fewer to 34 more) ΟΟΟ VERY LOW CRITICAL
  10% 27 fewer per 1,000 (from 68 fewer to 68 more)
  20% 54 fewer per 1,000 (from 136 fewer to 136 more)
Hospitalization due to respiratory infection
1 Observational studies Serious4 No serious inconsistency No serious indirectness No serious imprecision None 5% RR 0.87 (0.69–1.09)5 6 fewer per 1,000 (from 16 fewer to 5 more) ΟΟΟ VERY LOW CRITICAL
  10% 13 fewer per 1,000 (from 31 fewer to 9 more)
  20% 26 fewer per 1,000 (from 62 fewer to 18 more)
ICU admission
1 Observational studies Serious9 No serious inconsistency No serious indirectness No serious imprecision None 184/2,696 (6.8%) RR 0.19 (0.14–0.27) 55 fewer per 1,000 (from 50 fewer to 59 fewer) ΟΟΟ VERY LOW CRITICAL
  12% 97 fewer per 1,000 (from 88 fewer to 103 fewer)
  25% 203 fewer per 1,000 (from 183 fewer to 215 fewer)
Influenza-like illness
1 Observational studies Serious10 No serious inconsistency No serious indirectness No serious imprecision None 5% RR 0.88 (0.86–0.9)11 6 fewer per 1,000 (from 5 fewer to 7 fewer) ΟΟΟ VERY LOW CRITICAL
  10% 12 fewer per 1,000 (from 10 fewer to 14 fewer)
  20% 24 fewer per 1,000 (from 20 fewer to 28 fewer)
  1. 1High risk of bias in two of four studies due to inappropriate adjustment for confounders and unclear baseline imbalance.
  2. 2Control group rates available in only two of four studies.
  3. 3RR adjusted in all four studies at least for age, sex, and comorbidities.
  4. 4High risk of bias due to missing information on comorbidities in vaccinated vs. non-vaccinated participants.
  5. 5Adjusted for age, sex, ethnicity, network, length of time with ESRD, cause of renal failure, comorbidity index, and hospital days.
  6. 6Control group rate available only for one of two studies.
  7. 7RR adjusted in both studies at least for age, sex, and comorbidities.
  8. 8High risk of bias in three of four studies due to inappropriate adjustment for confounders, unclear baseline imbalance, and inappropriate follow-up time.
  9. 9High risk of bias due to inappropriate adjustment for confounders.
  10. 10Significant estimate of effectiveness outside influenza season indicates residual confounding.
  11. 11Adjusted for sex, age, cause of ESRD, vintage, adherence, hospital days, mobility aids, network, comorbidities, and oxygen use.
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