OBJECTIVE: To determine the effect of renal function at the commencement of dialysis on nutritional state. DESIGN: Retrospective cohort study. SETTING: University tertiary referral hospital. PATIENTS: Patients with end-stage renal disease commencing renal replacement therapy over 8.5 years. MAIN OUTCOME MEASURES:Total body nitrogen assessment using in vivo neutron activation analysis, expressed as nitrogen index (NI = observed total body nitrogen/predicted total body nitrogen); serum albumin measurement and creatinine clearance estimation, using the Cockcroft-Gault equation, at the start of dialysis. "Early" start group = creatinine clearance > 10 mL/minute (n = 26). "Late" start group = creatinine clearance < or = 10 mL/min (n = 108). RESULTS: Mean NI was significantly lower [95% confidence interval (CI) 6%-30%, p < 0.0001] in the late start group (NI = 88%) compared to the early start group (NI = 106%). The late start group also had a significantly lower (95% CI 0.06-0.47 g/dL, p = 0.02) mean serum albumin level (3.66 g/dL) compared to that of the early start group (3.93 g/dL). A positive independent correlation existed between renal function and total body nitrogen (r2 = 0.21, p < 0.0001). No other clinical or demographic variable at the start of dialysis was found to predict nutritional state. CONCLUSIONS: Patients that start dialysis with low levels of renal function are likely to be significantly malnourished. Whether this translates into a survival advantage requires prospective study.

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