Managing Sleep, Emotional Well-Being, and Quality of Life in Hemodialysis Patients via Acupressure [Response to Letter]

We sincerely appreciate the insightful comments and constructive suggestions from Zhao et al 1 regarding our systematic review and meta-analysis on acupressure for hemodialysis (HD) patients. 2Their perspectives on methodological optimization are of great value for improving the quality of evidence synthesis in this field and guiding subsequent clinical research and practice.We hereby respond to each of their concerns point by point with rigorous evidence and methodological explanations. Response to the Limitation of Single Timepoint Selection in Meta-SynthesisWe recognize that selecting the most frequently reported follow-up timepoint for outcome analysis may mask the temporal and cumulative effects of acupressure.This is a methodological trade-off made under the premise of balancing study heterogeneity and statistical validity.First, the 27 included studies showed significant heterogeneity in follow-up durations (28 days, 30 days, 56 days, 90 days, etc.), and consistent timepoint selection is a standardized processing method recommended by the PRISMA 2020 guidelines for meta-analyses with high follow-up time heterogeneity, which can avoid the bias caused by mixing different timepoint data in a single analysis. 3econd, we have explicitly stated this limitation in the Strengths and Limitations section of our original study and pointed out that subsequent research should explore the time-effect relationship of acupressure through long-term followup and stratified analysis.Third, the dose-response meta-analysis and subgroup analysis by intervention duration suggested by Zhao et al 1 are indeed valuable research directions, but the current included studies lack unified reporting of acupressure dose (eg, pressure intensity, cumulative operation time) and long-term follow-up data (≥6 months), which makes it impossible to conduct valid dose-response and long-term effect analysis. 4In the future, we will follow their suggestion to conduct further evidence synthesis when more high-quality studies with standardized timepoint and dose reporting are available. Response to Low-Certainty Evidence Does Not Imply Limited Clinical RelevanceWe appreciate Zhao et al's 1 careful verification of the weighted mean difference (WMD) and minimal important difference (MID) for social functioning outcomes.Our description of acupressure having "little impact" on social functioning is a comprehensive judgment that combines Grading of Recommendations, Assessment, Development and Evaluation (GRADE) evidence certainty and clinical effect reliability, rather than a negation of the observed effect size.