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and the training of research investigators in several important fields of renal and urologic research. The Board also recommended a separate NIH institute for kidney and urologic diseases. Readers are referred to the NKUDAB report for additional discussion of its important recommendations.

This committee has focused more sharply on the research issues that pertain to ESRD and, potentially, to its prevention. In the judgment of the committee, a serious need exists to reestablish a program of clinical studies on dialysis treatment. The termination of the Artificial Kidney/Chronic Disease research program of the National Institute of Arthritis and Metabolic Diseases (predecessor to NIDDK) left major gaps in clinical studies of dialysis. NIDDK, in the period from 1984 to 1989, supported basic research on transplantation and cellular and subcellular studies of the kidney, but made no awards for clinical dialysis studies (Levin et al., 1990).

Other sources of support for clinical research in dialysis have declined. The Department of Veterans Affairs supports practically no clinical dialysis studies in its internally funded research programs (Levin et al., 1990). Baxter Healthcare recently launched an important research program (Baxter, 1990), but the private sector in general has funded little clinical research. Perhaps reflecting declining research support, the number of clinical dialysis papers presented at the annual meetings of the American Society of Artificial Internal Organs and the American Society of Nephrology has declined (Maher, 1989).

Overall, the decline in dialysis research has two primary effects. First, it reduces the rate at which new clinical research is generated and thus restricts the flow of scientific information to dialysis clinicians. This may have been costly in the past decade during which the clinical community was placed under increasing financial stress by Medicare reimbursement reductions at a time when it was perhaps in greatest need of the benefits of clinical research. In particular, the discussion among clinicians of unresolved issues regarding the adequacy of dialysis, the effective delivery of the dialysis prescription, the effects of short treatment time on patient outcomes, and the relationship of nutrition to outcomes highlights the need for sustained clinical research.

Second, without clinical studies, the reservoir of scientific ideas necessary to stimulate innovation in treatment technology is not replenished. Without public support for research on underlying issues, private commercialization of new products is dampened. Economic studies have shown that the societal benefits from research exceed the private return on research, thus resulting in underinvestment by the private sector in the socially optimal level of research and strongly arguing for public support (Mansfield et al., 1977).

Research on the prevention of permanent kidney failure is essential to reduce the anticipated growth of the ESRD patient population. Recent laboratory investigations indicate that progression of established kidney disease can be slowed or possibly even prevented by various techniques. These include alterations in certain dietary constituents (protein, phosphate) and



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