The joint association of malnutrition and activities of daily living dependence with adverse health outcomes among patients initiating maintenance dialysis

Background: While prior work has examined activities of daily living (ADL) dependence and malnutrition separately, the additive effects of these conditions remain uncertain. Therefore, the purpose of this study was to evaluate the joint association of malnutrition and ADL dependence with poor health outcomes in incident dialysis patients. Methods: 1457 patients from the Aichi Cohort Study of Prognosis in Patients Newly Initiated into Dialysis database were identified for inclusion in this longitudinal study. The geriatric nutritional risk index and Barthel index were used as the evaluation tool for nutritional status and functional ability. Combined classifications of malnutrition and ADL dependence were generated with four subgroups derived. Associations between these exposures and health outcomes, including all-cause mortality, major adverse cardiovascular events (MACE), and infection-related death were investigated using Cox-proportional hazard models and competing risk survival models, respectively. Results: 39.5% of the participants were not malnourished nor ADL dependent (normal), 30.3% were malnourished, 10.5% ADL dependent and 19.8% as having both malnutrition and ADL dependence. During 4752 person-years of follow-up, 367 (25.2%) died and 650 (44.6%) patients suffered a MACE. Compared with the reference group (ADL dependency and no-malnutrition), the combination malnourished/ADL dependent showed the strongest association with all cause death (fully-adjusted HR 2.64, 95% CI 1.79–3.89), mortality from infection (fully-adjusted HR 4.41, 95% CI 1.88–10.40), and MACE incidence (fully-adjusted HR 1.81, 95% CI 1.36–2.42). This relationship remained credible and robust in several subgroup and sensitivity analyses. Additionally, we identified this associations were higher in patients aged 75 and older. Conclusion: The concurrent presence of malnutrition and ADL dependence at the time of dialysis initiation has significant detrimental impacts.