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American Journal of Kidney Diseases

Prehemodialysis Care by Dietitians and First-Year Mortality After Initiation of Hemodialysis

      Background

      Since January 2002, Medicare has provided payment for medical nutrition therapy for patients with chronic kidney disease. Few patients receive dietary counseling before end-stage renal disease onset; whether such counseling is associated with improved outcomes is unknown.

      Study Design

      Retrospective cohort analysis.

      Setting & Participants

      Patients who initiated hemodialysis therapy on June 1, 2005, to May 31, 2007, in the United States for whom predialysis dietitian care was reported on the Centers for Medicare & Medicaid Services Medical Evidence Report.

      Predictor

      Dietitian care before end-stage renal disease onset.

      Outcome

      Time to death.

      Measurements

      Propensity score for dietitian care calculated using logistic regression; Cox regression analysis used to compare time to death by predialysis dietitian care overall and stratified by tertiles of propensity score, adjusting for baseline characteristics.

      Results

      Most patients (88%) received no dietitian care; 9% received dietitian care for 12 months or less, and 3% received dietitian care for more than 12 months before dialysis therapy initiation (total N = 156,440). Predialysis dietitian care was associated independently with higher albumin and lower total cholesterol levels at dialysis therapy initiation. There was evidence of an independent association between predialysis dietitian care for longer than 12 months and decreased mortality during the first year on dialysis therapy for the second tertile of propensity score. Adjusted mortality HRs were 1.16 (95% CI, 0.44-3.09; P = 0.8), 0.81 (95% CI, 0.71-0.93; P = 0.002), and 0.93 (95% CI, 0.86-1.01; P = 0.1) in the first, second, and third tertiles of propensity score, respectively.

      Limitations

      Information for dietitian care was missing for 18.6% of Medical Evidence Reports and has low sensitivity; including only incident dialysis patients precluded evaluation of an association between dietitian care and chronic kidney disease progression; the observational design allowed the possibility of residual confounding.

      Conclusions

      Our study suggests an independent association between predialysis dietitian care for more than 12 months and lower mortality during the first year on dialysis therapy.

      Index Words

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      Linked Article

      • Predialysis Care: Intertwined Roles of Nephrologists and Dietitians
        American Journal of Kidney DiseasesVol. 59Issue 2
        • Preview
          Slinin et al1 provide an important analysis about the impact of dietitian care on mortality of incident hemodialysis patients. As the third table in their supplementary online material shows, the benefit of dietitian care for more than 12 months is offset when the analysis is adjusted for the variable of care by a nephrologist. With this in mind, I would like to offer several other explanations for the mortality differences observed by Slinin et al.
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