Frequent Predialysis Nephrology Care Is Associated With Improved Survival After Dialysis Initiation

Background and hypothesis End-stage kidney disease (ESKD), a severe complication of chronic kidney disease (CKD), carries high mortality, morbidity, and significant financial and emotional burdens. The frequency of pre-dialysis care may influence survival after initiation of kidney replacement therapy (KRT), yet its role remains poorly defined. The study aimed to evaluate whether the frequency of nephrology visits during the 12 months before initiation of KRT among patients referred early was associated with post-dialysis mortality. Methods This retrospective registry-based cohort study included adults (≥18 years) from the CKD.QLD Registry (2011–2018) who progressed to ESKD and received KRT for more than 90 days. Early referrals (≥12 months before KRT) from seven Queensland public kidney clinics were analysed. Pre-dialysis visit frequency was assessed both categorically (1–4 vs ≥ 5 visits) and continuously using a multivariable Cox model with restricted cubic splines (four knots at 5, 10, 20, and 30 visits). Models were adjusted for age, sex, Indigenous status, socioeconomic status, baseline estimated glomerular filtration rate (eGFR), and comorbidity score. Results A total of 378 participants were included (median age 58 years; 61.6% male; 15.3% Indigenous), with 91 deaths (24.1%) during follow-up. Mortality was higher among patients with fewer than 5 visits than among those with 5 or more visits (40.7% vs 21.0%). Continuous analysis demonstrated a significant non-linear association between visit frequency and mortality (p = 0.005, 0.017, and 0.020 for spline terms). Mortality risk decreased sharply as visit frequency increased up to approximately 5-6 visits, beyond which the hazard ratio remained consistently below 1.0, supporting this threshold as protective. Older age and higher baseline eGFR were independently associated with mortality. Conclusion Greater frequency of pre-dialysis nephrology visits was associated with improved survival after KRT in a non-linear pattern. These findings support the importance of consistent engagement with nephrology services in the final year before dialysis and highlight the need for structured pre-dialysis care pathways.