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Context: High dietary phosphorus intake has deleterious consequences for renal patients and is possibly harmful for the general public as well. To prevent hyperphosphatemia, patients with end-stage renal disease limit their intake of foods that are naturally high in phosphorus. However, phosphorus-containing additives are increasingly being added to processed and fast foods. The effect of such additives on serum phosphorus levels is unclear.Objective: To determine the effect of limiting the intake of phosphorus-containing food additives on serum phosphorus levels among patients with end-stage renal disease.Design, Setting, and Participants: Cluster randomized controlled trial at 14 long-term hemodialysis facilities in northeast Ohio. Two hundred seventy-nine patients with elevated baseline serum phosphorus levels (>5.5 mg/dL) were recruited between May and October 2007. Two shifts at each of 12 large facilities and 1 shift at each of 2 small facilities were randomly assigned to an intervention or control group.Intervention: Intervention participants (n=145) received education on avoiding foods with phosphorus additives when purchasing groceries or visiting fast food restaurants. Control participants (n=134) continued to receive usual care.Main Outcome Measure: Change in serum phosphorus level after 3 months.Results: At baseline, there was no significant difference in serum phosphorus levels between the 2 groups. After 3 months, the decline in serum phosphorus levels was 0.6 mg/dL larger among intervention vs control participants (95% confidence interval, -1.0 to -0.1 mg/dL). Intervention participants also had statistically significant increases in reading ingredient lists (P<.001) and nutrition facts labels (P = .04) but no significant increase in food knowledge scores (P = .13).Conclusion: Educating end-stage renal disease patients to avoid phosphorus-containing food additives resulted in modest improvements in hyperphosphatemia.Trial Registration: clinicaltrials.gov Identifier: NCT00583570. [ABSTRACT FROM AUTHOR]

This article presents the results of a study that sought to see if poor populations could be informed of their entitled health services and if they were, if that would increase the delivery of heath services. Developing countries have a real problem with health care delivery even if the services are available. Inadequate service delivery often results from a lack of accountability by the health care workers and since the population generally doesn't know what they are entitled to, they rarely urge for service. The study found that informing the public did positively effect the delivery of health and social services and the authors conclude that patient education programs may improve the delivery of services elsewhere.

Context: By improving the process of care, quality improvement efforts have the potential to reduce race and sex disparities. However, little is known about whether reductions actually occur. National quality improvement activities targeting hemodialysis patients provide an opportunity to examine this issue. Objective: To determine the effect of quality improvement efforts on race and sex disparities among hemodialysis patients. Design, Setting, and Subjects: Longitudinal study of 58 700 randomly selected hemodialysis patients from throughout the United States in 1993 through 2000. Intervention: Medicare-funded quality improvement project involving monitoring of patient outcomes, feedback of performance data, and education of clinicians at dialysis centers. Main Outcome Measures: Changes in hemodialysis dose (Kt/V), anemia management (hemoglobin level), and nutritional status (albumin level). Results: The proportion of all patients with an adequate hemodialysis dose increased 2-fold. In 1993, 46% of white patients and 36% of black patients received an adequate hemodialysis dose compared with 2000 when the proportions were 87% and 84%, respectively. Thus, the gap between white and black patients decreased from 10% to 3% (P<.001). The gap between female and male patients decreased from 23% to 9% over the same period (P = .008). The proportion of all patients with adequate hemoglobin levels increased 3-fold. The proportion of all patients with adequate albumin levels remained unchanged. Race and sex disparities in anemia management and nutritional status did not change significantly. Conclusions: Quality improvement efforts have a variable impact on race and sex disparities in health outcomes. Further work is needed to determine how quality improvement methods can be targeted to reduce health disparities. [ABSTRACT FROM AUTHOR]

Context: Many countries have a shortage of kidneys available for transplantation. Paying people to donate kidneys is often proposed or justified as a way to benefit recipients by increasing the supply of organs and to benefit donors by improving their economic status. However, whether individuals who sell their kidneys actually benefit from the sale is controversial. Objective: To determine the economic and health effects of selling a kidney. Design, Setting, and Participants: Cross-sectional survey conducted in February 2001 among 305 individuals who had sold a kidney in Chennai, India, an average of 6 years before the survey. Main Outcome Measures: Reasons for selling kidney, amount received from sale, how money was spent, change in economic status, change in health status, advice for others contemplating selling a kidney. Results: Ninety-six percent of participants sold their kidneys to pay off debts. The average amount received was $1070. Most of the money received was spent on debts, food, and clothing. Average family income declined by one third after nephrectomy (P<.001), and the number of participants living below the poverty line increased. Three fourths of participants were still in debt at the time of the survey. About 86% of participants reported a deterioration in their health status after nephrectomy. Seventy-nine percent would not recommend that others sell a kidney. Conclusions: Among paid donors in India, selling a kidney does not lead to a long-term economic benefit and may be associated with a decline in health. Physicians and policy makers should reexamine the value of using financial incentives to increase the supply of organs for transplantation. [ABSTRACT FROM AUTHOR]

Context: Mortality rates among US hemodialysis patients are the highest in the industrialized world at 23% per year. Measures of dialysis dose (Kt/V) correspond strongly with survival and are inadequate in one sixth of patients. Inadequate dialysis is also associated with increased hospitalizations and high inpatient costs. Our previous work identified 3 barriers to adequate hemodialysis: dialysis underprescription, catheter use, and shortened treatment time. Objective: To determine the effect of a tailored intervention on adequacy of hemodialysis. Design and Setting: Community-based randomized controlled trial with recruitment from April 1999 to June 2000 at 29 hemodialysis facilities in northeast Ohio. Participants: Forty-four nephrologists and their 169 randomly selected adult patients receiving inadequate hemodialysis. Intervention: Nephrologists were randomly assigned to an intervention (n = 21) or control (n = 23) group. For patients in the intervention group (n = 85), depending on the barrier(s) present, a study coordinator gave nephrologists recommendations about optimizing dialysis prescriptions, expedited conversion of catheters to surgically created grafts or fistulas, and educated patients about the importance of compliance with treatment time. Patients in the control group (n = 84) continued to receive usual care. Main Outcome Measures: Changes in Kt/V and specific barriers after 6 months. Results: At baseline, intervention and control patients had similar Kt/V measurements, specific barriers, and demographic and medical characteristics. After 6 months, intervention patients had 2-fold larger increases in Kt/V compared with control patients (+0.20 vs +0.10; P<.001) and were more likely to achieve their facility Kt/V goal (62% vs 42%; P = .01). Intervention patients also had nearly 3-fold larger increases in dialysis prescription (+0.16 vs +0.06; P<.001) and were 4 times more likely to change from use of catheters to use of fistulas/grafts (28% vs... [ABSTRACT FROM AUTHOR]

Focuses on a study which determines the relative importance of steps in explaining differences in cadaveric renal transplantation rates. Methods used in the study; Steps in the transplant process; Limitations of the study.

Presents a study, the objective of which was to determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany and Japan. Design; Participants; Main outcome measures; Results; Conclusions.

A response by Ashwini R. Sehgal, Catherine Sullivan, and Srilekha S. Sayre to a letter to the editor about their article "Effect of Food Additives on Hyperphosphatemia Among Patients With End-Stage Renal Disease: A Randomized Controlled Trial" in the 2009 issue is presented.