New Developments in CKD-MBD. How can we produce useful evidence-based guidelines in the field of CKD-MBD?

Abstract

The target ranges of laboratory measures, such as calcium and phosphorus, in the current CKD-MBD guidelines have been mainly determined by large observational studies examining the association between laboratory values and mortality. However, the suggested optimal ranges are often different between observational studies and randomized controlled trials (RCTs) . For example, in the field of diabetes mellitus, cohort studies showed that the lower hemoglobin A1c levels were associated with better clinical outcomes. However, intensive control of blood sugar resulted in higher mortality in RCTs. In order to advocate really meaningful guidelines, we have to conduct many RCTs. In other words, a paradigm shift from "setting targets" to "comparing the intensity of a medical treatment" is necessary, because target ranges might be dependent on the type of the drug or intervention. If we cannot conduct RCTs because of ethical reasons or economic issues, sophisticated analysis methods such as propensity score-based analysis and facility-level analysis should be employed in observational studies.