Spanish 11-50-0166) •Diabetes and Chronic Kidney Disease (Stages 1–4) (English 11-10-0209; Spanish 11-10-0240) •Dining Out with Confidence: A Guide for Kidney Patients (11-10-0405) •GFR (Glomerular Filtration Rate): A Key to Understanding How Well Your Kidneys Are Working (11-10-1813) •Staying Fit with Kidney Disease (11-10-0502) •Your Kidneys: Master Chemists of the Body (11-10-0103). www.kidney.org 21 Fact Sheets: Fact sheets can be found online at: www.kidney.org/atoz/ •How to Increase Calories in Your CKD Diet •Phosphorus and Your CKD Diet •Potassium and Your CKD Diet •Sodium and Your CKD Diet: How to Spice Up Your Cooking •Vitamins and Minerals in Kidney Disease. •Enjoy Your Own Recipes Using Less Protein mproving Nutrition Research in Nephrology: An Appetite for Change Related Article, p. 576 The doctor of the future will no longer treat the human frame with drugs, but rather will cure and prevent disease with nutrition. -Thomas Edison Patients affected by chronic kidney disease (CKD) and their health practitioners have a strong but unmet appetite for nutritional interventions.1,2 In a recent national workshop, patients, caregivers, and clinicians ranked investigating the potential of lifestyle programs to prevent deteriorating kidney function as their highest priority for CKD research.2 Dietary and lifestyle interventions not only engender the notions and ideals of self-management, but can improve quality of life, lived experiences, and patient outcomes. However, despite the strong biological plausibility of nutritional interventions to improve health, empirical evidence of their effectiveness to sustainably improve clinical and patient-reported outcomes among adults and children with CKD is strikingly lacking. Historically in CKD, considerably more scientific attention has been paid to modifying single nutrients such as phosphorus and protein, without obvious benefits and possible harm to patients and families as they contend with complex, unintuitive, and at times contradictory dietary adjustments. In this issue, Meuleman and her colleagues3 have endeavored to address this growing call for nutritional trials in CKD with their ESMO (Effects of Sodium Modification on Outcome of CKD) Study. In their open-label randomized controlled trial involving 4 Dutch centers, 138 adults with hypertension, CKD (estimated glomerular filtration rate $ 20 mL/ min/1.73 m2 and proteinuria with protein excretion $ 0.2 g/L or 0.3 g/d), and high urinary sodium excretion ($120 mmol/d) were randomly allocated to selfmanaged dietary sodium restriction (weekly to fortnightly coaching together with feedback and instruction in self-monitoring of blood pressure and sodium intake) or usual care according to national guidelines for 3 months. The self-management intervention, which received high patient-reported satisfaction scores, led to small and imprecise clinical decreases in the primary outcomes of sodium intake (estimated by 24-hour urinary sodium excretion) and blood pressure at 3 months, as well as in the secondary outcomes of proteinuria and body weight. Selfefficacy, a mediator of behavior change, was modestly improved, although the need for antihypertensive medications, kidney function, and health-related quality of life was not significantly changed. After participants were followed up for an additional 3 months without ongoing intervention, urinary sodium excretion and ambulatory blood pressure measurements were no longer different between the 2 groups, although the modest improvements in office blood pressure, proteinuria, body weight, and self-efficacy persisted among those who received the intervention. The authors concluded that a theory-based selfmanagement intervention to lower sodium intake was of small benefit to patients with CKD, although the benefits diminished over time despite high levels of patient acceptability. This study addresses an area of clinical importance, that of dietary salt intake, using a patient-centered approach. High sodium intake has important pathobiological consequences for kidney function, including tissue injury, fibrosis, renin-angiotensin system activation, diminished pharmacotherapeutic efficacy, and accelerated progression of kidney failure.4,5 Despite this, there is ongoing debate about the lower limit of dietary sodium intake, fueled by uncertainty from observational research. Trials in CKD to date have been of short duration with low statistical power and have been hampered by methods that cannot be implemented in day-to-day clinical practice or that are misaligned with patient preferences.6 For example, to achieve different levels of sodium intake, trial participants have often received oral sodium supplementation rather than dietary change, which although important to test biological effect, does little to translate research into effective practice. The ESMO Study set out to change this approach in CKD by testing a patientfocused approach explicitly intervening on behavioral feedback loops that might be important in driving the personal changes needed to lower sodium intake and therefore blood pressure. The ESMO trial have several important implications for clinical practice and trial design in nephrology. First, the study provided an exemplar for