A randomized controlled trial of different serum phosphate ranges in subjects on hemodialysis

BackgroundHyperphosphataemia in dialysis subjects is associated with increased mortality. However cause and effect has not been proven, and the ideal phosphate target range is unknown despite KDOQI's call for studies over 12years ago. The design and conduct of a randomized controlled trial is challenging because maintaining two groups within differing target ranges of serum phosphate has not been achieved over a long follow-up of 1year, in a trial setting, before. The SPIRiT study examines the subject acceptance, recruitment and retention rates for such a study in which subjects were randomised to two distinct serum phosphate concentrations, then titrated and maintained over 12months.MethodsA two center trial of 104 hemodialysis subjects randomized to lower range LRG 0.8-1.4mmol/L or 2.5-4.3mg/dL) and higher range (HRG 1.8-2.4mmol/L or 5.6-7.4mg/dL) serum phosphate groups. Two months' titration and ten months' maintenance phase. Interventions were non-calcium phosphate binders, self-help questionnaires, with blood tests at specified time intervals.ResultsThirteen percent of the eligible dialysis population were successfully recruited. A mean separation by serum phosphate of 1.1mg/dL was achieved and maintained between the groups over 10months. Drop-out rate was 27% with mortality 10%. Nine subjects in the HRG (17.6%) and two subjects in the LRG (3.8%) died during the study, however the study was not powered to detect significant differences in outcomes.ConclusionRandomizing dialysis subjects to separate treatment targets for serum phosphate can achieve a clinically significant sustained separation over 12months. A large scale longer term study is required to examine outcomes including mortality.Trial registrationThe trial registration number is ISRCTN24741445 - Date of registration 16th January, retrospectively registered.