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We included 23495 HD patients; 3662 were incident. Females and older patients have lower baseline SCI. Higher SCI was associated with a lower risk of mortality [hazard ratio 0.81 (95% confidence interval 0.79-0.82)]. SCI decline accelerated ∼5-7 months before death. Lean tissue index (LTI) estimated by SCI was correlated with measured LTI in both sexes (males R2 = 0.94; females R2 = 0.92; both P 0.001). Bland-Altman analysis showed that measured LTI was 4.71 kg/m2 (±2SD -12.54-3.12) lower than estimated LTI. SCI is a simp