#1876 Pre-dialysis nutrition intervention is associated with delayed time to dialysis and survival after initiation of dialysis
Authors: Chan Maria , Turner Kylie , Kelly John , Katz Ivor , Batterham Marijka , Webster Angela 
Published: May 2024

Abstract

Background and Aims
Nutrition intervention (NI) is recommended in multidisciplinary pre-dialysis care as best evidence-based practice. NI aims to preserve kidney function, optimise nutritional status, attain optimal body weight/composition, and control complications and symptoms. However, understanding of its effectiveness on delaying dialysis and survival is limited. This study, Dietary Approaches to Manage Progressive and End stage Renal disease (DAMPER) study aimed to examine the effect of NI on time to dialysis and survival in patients attending a Kidney Disease Education Clinic (KDEC) and receiving structured NI from a dietitian.

Method
A retrospective clinical cohort study to examine patients who attended a KDEC at a metropolitan teaching hospital April 2002 through December 2019, followed up until December 2021. Associations of time to dialysis and mortality were compared between patients who received NI (NI group) and those who did not (no-NI group). Data were adjusted for baseline characteristics using Cox proportion hazard model, including age, gender, estimated glomerular filtration rate (eGFR), presence of co morbidities (e.g., diabetes mellitus, DM, peripheral vascular disease, PVD), and subjective global assessment (SGA) with score A=well-nourished, B or C=malnourished.

Results
1138 patients attended the KDEC, 670 patients commenced dialysis and 538 met inclusion criteria for the study. 64.5% were male, median age 65 years (IQR 57–72), eGFR 15 mL/min/1.73 m2 (IQR 13–19), and prevalence of malnutrition (SGA=B and C) was 28.7%. 342 (63.6%) patients were in the NI group, only 84 (15.6%) had already commenced NI before KDEC. There was no statistical difference for the baseline age, gender, eGFR, PVD and DM (NS). However, prevalence of malnutrition was significantly higher in the non-NI group vs NI group (30.0% vs 28.1%, p = 0.002). By the end of the observation period, 503 (93.5%) patients had commenced dialysis, with 314/342 (91.8%) for the NI group vs 189/196 (96.4%) for the no-NI group (p = 0.037). The NI group reached dialysis significantly later compared to the no-NI group: 28.2 mo (95% CI 25.1–31.3) vs 18.8 mo (95% CI 15.7–22.0), respectively (log rank 0.000; hazard ratio [HR] 0.63; 95% CI 0.51–0.77; p = 0.000). Other factors significantly associated with time to dialysis were eGFR (p = 0.000) and PVD (p = 0.020). Age, gender, presence of malnutrition and diabetes were not associated with time to dialysis (NS). The NI-group was also associated with better survival compared to the no-NI group: time to mortality 116.6 mo (95% CI 106.1–127.2) vs 94.5 mo (95% CI 84.2-104.7), p = 0.001, respectively (log rank 0.005). None of these factors were independently associated with mortality (NS).

Conclusion
Structured pre-dialysis NI significantly delayed time to dialysis and reduced mortality risk in people with chronic kidney disease. Timely referral to NI is recommended in pre-dialysis care and KDEC provides an important platform for dietitians to initiate NI.