Reply-letter to the editor-effects of omega-3 polyunsaturated fatty acid intake in patients with chronic kidney disease: Systematic review and meta-analysis of randomized controlled trials

We thank Kumar A. and Shariff M et al. for conducting a trial sequential analysis (TSA) on our meta-analysis of omega 3 fatty acid supplementation in chronic kidney disease. The authors estimated the required information size and trial sequential boundary to determine if the observed beneficial effect of omega 3 supplementation on cardiovascular mortality is conclusive or whether further evidence is needed. They found that an information size of 1314 is needed to detect a risk reduction of 56% in cardiovascular mortality with omega 3 supplementation. They assumed a power of 80%, an alpha of 5%, cardiovascular mortality rate of 5.26% in the control arm, and a diversity (D2) of 0%. While the required information size was not achieved (1314 versus a pooled information size of 1104 in our meta-analysis), the authors reported the z curve crossed the estimated trial sequential boundary after study 8. Therefore, they concluded that there is sufficient evidence to confirm the benefits of omega-3 supplementation on cardiovascular mortality and no further trials are needed. Of note, the estimates of effects and study heterogeneity were sourced from our meta-analyses.