Objective: The aim of this study was to explore the changes in nutritional status before dialysis initiation, and to identify modifiable risk factors of nutritional status decline in older adults with advanced renal disease. Design and methods: The European Quality Study on treatment in advanced chronic kidney disease (EQUAL) is a prospective, observational cohort study involving six European countries. We included 1103 adults >65 years with incident eGFR < 20 ml/min/1.73m² not on dialysis, attending nephrology care. Nutritional status was assessed with the 7 point Subjective Global Assessment tool (7-p SGA), patient-reported outcomes with RAND-36 and the Dialysis Symptom Index. Logistic regression was used to estimate the associations between potential risk factors and SGA decline. Results: The majority of the patients had a normal nutritional status at baseline, 28% were moderately malnourished (SGA ≤5). Overall, mean SGA decreased by -0.18 points/year, (95% CI -0.21; -0.14). More than one-third of the study participants (34.9%) deteriorated in nutritional status (1 point decline in SGA) and 10.9% had a severe decline in SGA (≥ 2 points). The proportion of patients with low SGA (≤5) increased every six months. Those who dropped in SGA also declined in eGFR and mental health score. Every 10 points decrease in physical function score increased the odds of decline in SGA by 23%. Lower physical function score at baseline, gastrointestinal symptoms and smoking were risk factors for impaired nutritional status. There was an interaction between diabetes and physical function on SGA decline. Conclusions: Nutritional status deteriorated in more than one-third of the study participants during the first year of follow-up. Lower patient reported physical function, more gastrointestinal symptoms, and current smoking were associated with decline in nutritional status.