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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.

Context: A lack of awareness about entitled health and social services may contribute to poor delivery of such services in developing countries, especially among individuals of low socioeconomic status., Objective: To determine the impact of informing resource-poor rural populations about entitled services., Design, Setting, and Participants: Community-based, cluster randomized controlled trial conducted from May 2004 to May 2005 in 105 randomly selected village clusters in Uttar Pradesh state in India. Households (548 intervention and 497 control) were selected by a systematic sampling design, including both low-caste and mid- to high-caste households., Intervention: Four to 6 public meetings were held in each intervention village cluster to disseminate information on entitled health services, entitled education services, and village governance requirements. No intervention took place in control village clusters., Main Outcome Measures: Visits by nurse midwife; prenatal examinations, tetanus vaccinations, and prenatal supplements received by pregnant women; vaccinations received by infants; excess school fees charged; occurrence of village council meetings; and development work in villages., Results: At baseline, there were no significant differences in self-reported delivery of health and social services. After 1 year, intervention villagers reported better delivery of several services compared with control villagers: in a multivariate analysis, 30% more prenatal examinations (95% confidence interval [CI], 17%-43%; P < .001), 27% more tetanus vaccinations (95% CI, 12%-41%; P < .001), 24% more prenatal supplements (95% CI, 8%-39%; P = .003), 25% more infant vaccinations (95% CI, 8%-42%; P = .004), and decreased excess school fees of 8 rupees (95% CI, 4-13 rupees; P < .001). In a difference-in-differences analysis, 21% more village council meetings were reported (95% CI, 5%-36%; P = .01). There were no improvements in visits by a nurse midwife or in development work in the villages. Both low-caste and mid- to high-caste intervention households reported significant improvements in service delivery., Conclusions: Informing resource-poor rural populations in India about entitled services enhanced the delivery of health and social services among both low- and mid- to high-caste households. Interventions that emphasize educating resource-poor populations about entitled services may improve the delivery of such services., Trial Registration: clinicaltrials.gov Identifier: NCT00421291.

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.

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 US dollars. 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.

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 7%; P =.04)., Conclusions: An intervention tailored to patient-specific barriers resulted in increased hemodialysis dose. Extending this approach to the 33 000 persons in the United States receiving inadequate hemodialysis may substantially enhance patient survival, diminish hospitalizations, and decrease inpatient expenditures.

Context: Cadaveric renal transplantation rates differ greatly by race, sex, and income. Previous efforts to lessen these differences have focused on the transplant waiting list. However, the transplantation process involves a series of steps related to medical suitability, interest in transplantation, pretransplant workup, and movement up a waiting list to eventual transplantation., Objective: To determine the relative importance of each step in explaining differences in cadaveric renal transplantation rates., Design: Prospective cohort study., Setting and Patients: A total of 7125 patients beginning long-term dialysis between January 1993 and December 1996 in Indiana, Kentucky, and Ohio., Main Outcome Measures: Completion of 4 separate steps during each patient-year of follow-up: (A) being medically suitable and possibly interested in transplantation; (B) being definitely interested in transplantation; (C) completing the pretransplant workup; and (D) moving up a waiting list and receiving a transplant., Results: Compared with whites, blacks were less likely to complete steps B (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.61-0.76), C (OR, 0.56; 95% CI, 0.48-0.65), and D (OR, 0.50; 95% CI, 0.40-0.62) after adjustment for age, sex, cause of renal failure, years receiving dialysis, and median income of patient ZIP code. Compared with men, women were less likely to complete each of the 4 steps, with ORs of 0.90, 0.89, 0.80, and 0.82, respectively. Poor individuals were less likely than wealthy individuals to complete steps A, B, and C, with ORs of 0.67, 0.78, and 0.77, respectively., Conclusions: Barriers at several steps are responsible for sociodemographic differences in access to cadaveric renal transplantation. Efforts to allocate kidneys equitably must address each step of the transplant process.

Objective: To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan., Design: Survey by questionnaire., Participants: Seventy-two American, 87 German, and 73 Japanese nephrologists., Main Outcome Measures: Each nephrologist's total number of (1) dialysis patients, (2) cases of withdrawal of dialysis, (3) patients with advance directives, and (4) uses of such directives. Nephrologists also stated whether they would continue or stop dialysis in 8 hypothetical cases., Results: American, German, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirty percent of American patients had advance directives, and such directives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such directives were used in decision making for 0.09% of patients. When asked about a hypothetical mentally incompetent patient whose family requests withdrawal of dialysis, American nephrologists were much more likely to stop dialysis in the absence of an advance directive than German or Japanese nephrologists. However, almost all nephrologists from the 3 countries would stop dialysis when a family request to withdraw was supported by a patient advance directive., Conclusions: There is a high prevalence of advance directives among American dialysis patients, and such directives frequently play a role in decision making. German and Japanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their use.