American Journal of Kidney Diseases

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


      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.


      Dietitian care before end-stage renal disease onset.


      Time to death.


      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.


      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.


      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.


      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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        • Gilbertson D.T.
        • Liu J.
        • Xue J.L.
        • et al.
        Projecting the number of patients with end-stage renal disease in the United States to the year 2015.
        J Am Soc Nephrol. 2005; 16: 3736-3741
      1. US Renal Data System.
        in: USRDS 2008 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2008
        • National Kidney Foundation
        KDOQI Clinical Practice Guidelines.
        (Accessed March 17, 2011)
      2. US Renal Data System.
        in: USRDS 2007 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2007
        • Rocco M.V.
        • Yan G.
        • Gassman J.
        • et al.
        Comparison of causes of death using HEMO Study and HCFA end-stage renal disease death notification classification systems.
        Am J Kidney Dis. 2002; 39: 146-153
        • Clase C.M.
        • St Pierre M.W.
        • Churchill D.N.
        Conversion between bromcresol green- and bromcresol purple-measured albumin in renal disease.
        Nephrol Dial Transplant. 2001; 16: 1925-1929
        • Bergstrom J.
        Nutrition and mortality in hemodialysis.
        J Am Soc Nephrol. 1995; 6: 1329-1341
        • Cliffe M.
        • Bloodworth L.L.
        • Jibani M.M.
        Can malnutrition in predialysis patients be prevented by dietetic intervention?.
        J Ren Nutr. 2001; 11: 161-165
        • Campbell K.L.
        • Ash S.
        • Zabel R.
        • McFarlane C.
        • Juffs P.
        • Bauer J.D.
        Implementation of standardized nutrition guidelines by renal dietitians is associated with improved nutrition status.
        J Ren Nutr. 2009; 19: 136-144
        • Morey B.
        • Walker R.
        • Davenport A.
        More dietetic time, better outcome?.
        Nephron Clin Pract. 2008; 109: c173-c180
        • Owen Jr, W.F.
        • Lew N.L.
        • Liu Y.
        • Lowrie E.G.
        • Lazarus J.M.
        The urea reduction ratio and serum albumin concentration as predictors of mortality in patients undergoing hemodialysis.
        N Engl J Med. 1993; 329: 1001-1006
        • Friedman A.N.
        • Fadem S.Z.
        Reassessment of albumin as a nutritional marker in kidney disease.
        J Am Soc Nephrol. 2010; 21: 223-230
        • Kloppenburg W.D.
        • Stegeman C.A.
        • Hovinga T.K.
        • et al.
        Effect of prescribing a high protein diet and increasing the dose of dialysis on nutrition in stable chronic haemodialysis patients: a randomized, controlled trial.
        Nephrol Dial Transplant. 2004; 19: 1212-1223
        • Akpele L.
        • Bailey J.L.
        Nutrition counseling impacts serum albumin levels.
        J Ren Nutr. 2004; 14: 143-148
        • Leon J.B.
        • Albert J.M.
        • Gilchrist G.
        • et al.
        Improving albumin levels among hemodialysis patients: a community-based randomized controlled trial.
        Am J Kidney Dis. 2006; 48: 28-36
        • Block G.A.
        • Hulbert-Shearon T.E.
        • Levin N.W.
        • Port F.K.
        Association of serum phosphorus and calcium x phosphate product with mortality risk in chronic hemodialysis patients: a national study.
        Am J Kidney Dis. 1998; 31: 607-617
        • Reddy V.
        • Symes F.
        • Sethi N.
        • et al.
        Dietitian-led education program to improve phosphate control in a single-center hemodialysis population.
        J Ren Nutr. 2009; 19: 314-320
        • Ford J.C.
        • Pope J.F.
        • Hunt A.E.
        • Gerald B.
        The effect of diet education on the laboratory values and knowledge of hemodialysis patients with hyperphosphatemia.
        J Ren Nutr. 2004; 14: 36-44

      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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