Abstract: FR-PO1036
Association of Dietitian Staffing on Diet-Sensitive Outcomes in Patients on Hemodialysis: A National Cohort Study
Session Information
- Hemodialysis: Clinical Challenges, Patient-Centered Outcomes, and Quality of Life
October 23, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 801 Dialysis: Hemodialysis and Frequent Dialysis
Authors
- Shi, Kevin Xin, University of California San Francisco, San Francisco, California, United States
- Plantinga, Laura, University of California San Francisco, San Francisco, California, United States
- Evans, Jennifer Lynn, University of California San Francisco, San Francisco, California, United States
- Tuot, Delphine S., University of California San Francisco, San Francisco, California, United States
Background
Dietitians play a key role in hemodialysis care, yet patient:dietitian ratios remain unstandardized. This study evaluates how staffing ratios relate to 1-year hospitalization, mortality, and control of phosphorus, albumin, and normalized protein catabolic rate (nPCR).
Methods
Using the US Renal Data System, we studied incident hemodialysis patients from 1/2019 to 9/2021, with a 3-month washout and 1-year follow-up. Patient:dietitian ratio, the primary predictor, was derived from yearly facility surveys. We used Cox proportional hazards models to estimate the association of staffing ratios with time to first hospitalization and death, with death as a competing risk for hospitalization. Linear mixed-effects models were used to estimate associations of ratios with summary diet-sensitive outcomes defined per patient as the proportion of months meeting lab thresholds: phosphorus < 5.5 mg/dL, albumin > 4.0 g/dL, and nPCR > 1.0 g/kg/day. All models were adjusted for age, sex, race, comorbidities (hypertension, diabetes, heart failure), and facility size, with facility as a random intercept.
Results
Among 255,113 patients and 7,450 centers (mean age, 63 years; 42% female, 63% white, 89% hypertensive, 63% diabetic) mean patient:dietitian ratio was 77:1, with 684 facilities reporting 0 dietitians in at least one annual survey. Among centers with > 0 dieticians, higher staffing ratios were associated with lower risks of all-cause (aHR per 10-unit increase: 0.993, 95% CI 0.990–0.996), fluid overload (0.992, 0.989–0.995), and hyperkalemia hospitalizations (0.994, 0.990–0.997; all p < 0.001), with no association with mortality (p = 0.40). Patient:dietitian ratio was not meaningfully associated with diet-sensitive outcomes: each 10-unit increase corresponded to a 0.1 percentage point increase in albumin adequacy (p < 0.001), a 0.1 percentage point decrease in nPCR adequacy (p < 0.001), and no difference in phosphorus control (p = 0.58).
Conclusion
Higher patient:dietitian ratios were slightly associated with better outcomes. These results warrant careful interpretation and may reflect residual confounding, ecologic fallacy, and/or challenges in quantifying the impact of renal dietitians rather than a true effect. Future directions include measuring patient-level measures of dietitian engagement directly and prospectively examining the effect of changes in dietitian staffing on outcomes.
Funding
- NIDDK Support