Abstract: We 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, I2 = 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, I2 = 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, I2 = 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. 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.

Plain-language summary: We searched the literature up to January 2016 and analysed 24 studies that involved 1787 participants. Of these, only seven studies provided data that could be combined for analysis. The studies reported that manual acupressure improved fatigue, depression and sleep disturbance when used as an adjunct to routine care for patients undergoing maintenance haemodialysis 4 weeks from baseline. No study assessed pain and most did not report whether adverse events of acupuncture occurred. Overall, we found very low quality evidence about the effectiveness of acupuncture for symptoms of CKD. Manual acupressure combined with routine care may provide short-term symptom relief from depressive mood, fatigue and sleep disturbance in patients undergoing haemodialysis. Findings from this review cannot support the benefits of other acupuncture techniques for patients with CKD because there were too few reliable studies. Pain is a common condition in patients with CKD. Thus, the potential role of acupuncture for pain control in patients with CKD deserves further research. Clinicians should carefully monitor the safety of acupuncture in patients with CKD unless sound evidence supports the safety of these interventions for CKD patients. All studies were assessed at high or unclear risk of bias, especially in terms of selection of participants and selective outcome reporting, which made the validity of their results doubtful.