The Association of Mediterranean and DASH Diets with Mortality in Adults on Hemodialysis: The DIET-HD Multinational Cohort Study

Abstract

Mediterranean and Dietary Approaches to Stop Hypertension (DASH) diets associate with lower cardiovascular and all-cause mortality in the general population, but the benefits for patients on hemodialysis are uncertain. Mediterranean and DASH diet scores were derived from the GALEN Food Frequency Questionnaire within the DIET-HD Study, a multinational cohort study of 9757 adults on hemodialysis. We conducted adjusted Cox regression analyses clustered by country to evaluate the association between diet score tertiles and all-cause and cardiovascular mortality (the lowest tertile was the reference category). During the median 2.7-year follow-up, 2087 deaths (829 cardiovascular deaths) occurred. The adjusted hazard ratios (95% confidence intervals) for the middle and highest Mediterranean diet score tertiles were 1.20 (1.01 to 1.41) and 1.14 (0.90 to 1.43), respectively, for cardiovascular mortality and 1.10 (0.99 to 1.22) and 1.01 (0.88 to 1.17), respectively, for all-cause mortality. Corresponding estimates for the same DASH diet score tertiles were 1.01 (0.85 to 1.21) and 1.19 (0.99 to 1.43), respectively, for cardiovascular mortality and 1.03 (0.92 to 1.15) and 1.00 (0.89 to 1.12), respectively, for all-cause mortality. The association between DASH diet score and all-cause death was modified by age (=0.03); adjusted hazard ratios for the middle and highest DASH diet score tertiles were 1.02 (0.81 to 1.29) and 0.70 (0.53 to 0.94), respectively, for younger patients (≤60 years old) and 1.05 (0.93 to 1.19) and 1.08 (0.95 to 1.23), respectively, for older patients. Mediterranean and DASH diets did not associate with cardiovascular or total mortality in hemodialysis.

Dietary Patterns and Mortality in a Multinational Cohort of Adults Receiving Hemodialysis

“…[8][9][10] However, these dietary patterns have not been shown to be associated with improved survival in hemodialysis patients. 11 Dietary guidelines suggest modifying the intake of individual nutrients in dialysis patients to control serum phosphate and potassium levels and fluid overload while maintaining a high protein and energy intake. [12][13][14] However, there is limited high-certainty evidence showing that targeting single nutrients improves clinical outcomes.…”

“…In a previous analysis of the DIET-HD study, we examined the association between existing dietary patterns (Mediterranean and DASH diets) and survival among hemodialysis patients in a multinational setting. 11 In the present analysis, principal component analysis has been conducted in the same cohort to generate data-driven patterns reflecting the eating behavior of the DIET-HD hemodialysis population. This approach can support greater understanding of the prognosis associated with real-world dietary practices in hemodialysis patients.…”

Diet Patterns—A Neglected Aspect of Hemodialysis Care

“…Unfortunately, there is a lack of definitive evidence to firmly support guidelines for best CKD dietary practices. 1 Thus, the study by Saglimbene et al 2 is a valuable addition to the CKD nutrition literature; however, the results overall are a letdown for those wanting more evidence to support current dietary advice.…”

“…In this issue of the Journal of the American Society of Nephrology, Saglimbene et al 2 report the results of a prospective, multinational cohort study that was undertaken by investigators from ten European countries and one South American country to examine the association of dietary patterns with mortality in adults on long-term hemodialysis. Nutrient intake was estimated by a food frequency questionnaire (FFQ) in a prevalent hemodialysis population (9757 people; mean age of 63.1 years old; 58% men).…”

Briefly Noted

“…14 A prospective, cohort study of 9757 HD patients in 11 countries found no cardiovascular or total mortality benefits associated with consumption of Mediterranean or DASH diets. The intake of 260 foods was assessed with their frequency of consumption classified into one of the eight categories from rarely/never to four or more times daily 15.…”