AbstractLower body mass index (BMI) has consistently been associated with mortality in elderly in the general and chronic disease populations. Remarkably, in older incident dialysis patients no association of BMI with mortality was found. We performed an in-depth analysis and explored possible time-stratified effects of BMI. 908 incident dialysis patients aged ≥65 years of the NECOSAD study were included, and divided into tertiles by baseline BMI (<23.1 (lower), 23.1–26.0 (reference), ≥26.0 (higher) kg/m²). Because the hazards changed significantly during follow-up, the effect of BMI was modeled for the short-term (<1 year) and longer-term (≥1 year after dialysis initiation). During follow-up (median 3.8 years) 567 deaths occurred. Lower BMI was associated with higher short-term mortality risk (adjusted-HR 1.63 [1.14–2.32] P = 0.007), and lower longer-term mortality risk (adjusted-HR 0.81 [0.63–1.04] P = 0.1). Patients with lower BMI who died during the first year had significantly more comorbidity, and worse self-reported physical functioning compared with those who survived the first year. Thus, lower BMI is associated with increased 1-year mortality, but conditional on surviving the first year, lower BMI yielded a similar or lower mortality risk compared with the reference. Those patients with lower BMI, who had limited comorbidity and better physical functioning, had better survival.