Usman

I think the results of EVOLVE trial are a redundant reminder that we should analyze them critically and adopt clinical practices cautiously if basing our clinical decisions on such trials. Many a time, the studies where surrogate markers are used to test the efficacy of a medication or the beneficence of a strategy, have failed to translate those positive results into a meaningful clinical benefit such as improved hard endpoints (mortality, CV events, etc). We all are aware of TREAT, DCCT and many ACEi/ARB trials where increasing HCT or reducing A1c or albuminuria does not translate into improved mortality. Regarding your other point Dr. Weinstein, whether a trial of phosphate control is ethical, I think it is not quite unethical to have a trial where one would randomize patients to standard/liberal vs. stricter control of serum phosphate. It is not unethical because of two reasons in my mind: the association between hyperphosphatemia and increased mortality is again observational and not proven by a RCT, secondly we will not be comparing the strategy with placebo but with standard or liberal therapy.