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Generalizability of RCTs
Acute MI
A total of 214 trials met inclusion criteria,
involving 150,920 study subjects.
Over 60% of trials excluded persons over
the age of 75 years.
Studies published after 1980 were more
likely to have age-based exclusions
compared with studies published before
1980
Gurwitz, JAMA, 1992
Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure.
N Engl J Med 1999;341:709-717. [
Rates of spironolactone
prescription
Juurlink et al. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study.
N Engl J Med. 2004 Aug 5;351(6):543-51.
Rates of death
Practice guidelines
Framework
Are the risks of the intervention comparable in older and younger patients?
Do the adverse effects of the intervention differ by age?
Do similar adverse effects have different implications for older and younger
patients?
Figure 2. Percentage of RCT versus total citations in nephrology and 12 other specialties of internal medicine
from 1966 to 2002
GFR (mL/min/1.732)
Early Treatment
10
Kidney Failure
0
7
Time (years)
11
Percent of patients
ACE DM 2
ARB DM
II
ACE or ARB
non-diabetic
CKD
All
Number of studies
11
31
Number of patients
775
4,941
4,267
6,451
16,434
3 (49-57)
5 (50-80)
3 (70-80)
7 (65-70)
18 (58%)
4 (67%)
3 (27%)
3 (60%)
7 (78%)
17 (55%)
Comorbidity exclusion, %
3 (50%)
9(82%)
4 (80%)
8 (89%)
24 (77%)
33.7
(28.9-39)
63.7 (4470.2)
59.4
(58.6-60)
63.3 (45.370.2)
60.8
2004 KDOQI guidelines on Hypertension and Anti-hypertensive agents in CKD; 2007 KDOQI guideline on Diabetes
and Chronic Kidney Disease
ALLHAT
Risk for end-stage renal disease (ESRD) (A), combined outcome of doubling of
serum creatinine or ESRD (B), or relative risk for these outcomes (CandD) in
patients taking angiotensin-converting enzyme inhibitors (squares) and controls
(circles), according to baseline urinary protein excretion
70.2 yr
59.7 yr
52.4 yr
Burden of co-morbidity
Summary patients
The vast majority of older individuals with CKD
do not have proteinuria and do not have
diabetes.
More than half of all non-proteinuric diabetic and
non-diabetic CKD occurs in those 70 or older.
Older patients with CKD have a higher
prevalence of co-existing cardiovascular disease
compared with their younger counterparts.
Summary trials
Most trials of ACE/ARB conducted among
populations with diabetes
Most have an upper age exclusion
Most have not enrolled participants older than 70
ALLHAT included the largest number of
participants (with and without diabetes) and had
the highest mean age and was a negative trial
ALLHAT participants accounted for 58% of all
participants in trials of non-diabetic CKD