Frailty, the state of increased vulnerability to physical stressors as a result of progressive and sustained degeneration in multiple physiological systems, is common in those with chronic kidney disease (CKD). In fact, the prevalence of frailty in the older adult population is reported to be 11%, whereas the prevalence of frailty has been reported to be greater than 60% in dialysis-dependent CKD patients. Frailty is independently linked with adverse clinical outcomes in all stages of CKD and has been repeatedly shown to be associated with an increased risk of mortality and hospitalization. In recent years there have been efforts to create an operationalized definition of frailty to aid its diagnosis and to categorize its severity. Two principal concepts are described, namely the Fried Phenotype Model of Physical Frailty and the Cumulative Deficit Model of Frailty. There is no agreement on which frailty assessment approach is superior, therefore, for the time being, emphasis should be placed on any efforts to identify frailty. Recognizing frailty should prompt a holistic assessment of the patient to address risk factors that may exacerbate its progression and to ensure that the patient has appropriate psychological and social support. Adequate nutritional intake is essential and individualized exercise programmes should be offered. The acknowledgement of frailty should prompt discussions that explore the future care wishes of these vulnerable patients. With further study, nephrologists may be able to use frailty assessments to inform discussions with patients about the initiation of renal replacement therapy.

Background: Understanding how frailty affects health-related quality of life (HRQOL) in those with chronic kidney disease (CKD) could assist in the development of management strategies to improve outcomes for this vulnerable patient group. This study aimed to evaluate the relationship between frailty and HRQOL in patients with CKD Stages 4 and 5 (G4–5) and those established on haemodialysis (G5D). Methods: Ninety participants with chronic kidney disease (CKD G4–5D) were recruited between December 2016 and December 2017. Frailty was assessed using the Frailty Phenotype, which included assessments of unintentional weight loss, weakness (handgrip strength), slowness (walking speed), physical activity and self-perceived exhaustion. HRQOL was assessed using the RAND 36-Item Health Survey Version 1.0 (SF-36). Results: Nineteen (21%) patients were categorized as frail. Frailty, when adjusted for age, gender, dialysis dependence and comorbidity, had a significant effect on five of the eight SF-36 domains: physical functioning, role limitations due to emotional problems, energy/fatigue, social functioning and pain. Regression modelling best explained the variation in the physical functioning domain (adj. R2 = 0.27, P < 0.001), with frailty leading to a 26-point lower score. Exhaustion was the only Frailty Phenotype component that had a significant effect on scores across all SF-36 domains. Conclusions: Frailty is independently associated with worse HRQOL in patients with CKD G4–5D, with self-perceived exhaustion being the most significant Frailty Phenotype component contributing to HRQOL. Efforts should be made to identify frail patients with CKD so that management strategies can be offered that aim to improve morbidity, mortality and patient-reported outcomes, including HRQOL and fatigue.

Background: Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality. Objective: This work describes the systematic codevelopment of “My Kidneys & Me” (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND). Methods: A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource. Results: The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M. Conclusions: Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial.

Rituximab, an anti-CD20 monoclonal antibody, was originally used to treat B-cell malignancies. Its use has significantly increased in recent years, as it is now also used to treat a variety of autoimmune diseases including rheumatoid arthritis and ANCA-associated vasculitis (AAV). Initial studies suggested that the adverse effects of rituximab were minimal. Though the risk of malignancy with rituximab-based immunosuppressive regimens appears similar to that of the general population, there are now concerns regarding the risk of infectious complications. Rituximab has been associated with serious infections, including Pneumocystis jiroveci pneumonia (PJP) and the reactivation of hepatitis B virus (HBV) and tuberculosis (TB). The risk of infection appears to be the result of a variety of mechanisms, including prolonged B-cell depletion, B-cell–T-cell crosstalk, panhypogammaglobulinaemia, late-onset neutropenia and blunting of the immune response after vaccination. Importantly, the risk of infectious complications is also related to individual patient characteristics and the indication for rituximab. Individualization of treatment is, therefore, crucial. Particular attention should be given to strategies to minimize the risk of infectious complications, including vaccinating against bacterial and viral pathogens, monitoring white cell count and immunoglobulin levels, prophylaxis against PJP and screening for HBV and TB.

Background/Aims: Frail patients with chronic kidney disease (CKD) have an increased hospitalisation and mortality rate. However, many popular frailty screening methods have not been validated in patients with CKD. This study evaluates the diagnostic accuracy of several frailty screening methods in patients with CKD G4–5 and those established on haemodialysis (G5D). Methods: Ninety participants with CKD G4–5D were recruited from Nephrology Outpatient Clinics and 2 Haemodialysis Units between December 2016 and December 2017. Frailty was diagnosed using the Fried Frailty Phenotype. The following frailty screening tests were evaluated: Clinical Frailty Scale, PRISMA-7, CKD Frailty Index, CKD FI-LAB, walking speed, hand grip strength and Short Physical Performance Battery. Results: The mean age of participants was 69 years (SD ±13). One-third of participants were dialysis-dependent. Nineteen (21%) patients were categorised as frail, 42 (47%) as pre-frail and 29 (32%) as robust. Overall, walking speed was the most discriminative measure (AUC 0.97 [95% CI 0.93–1.00], sensitivity 0.84 [95% CI 0.62–0.94], specificity 0.96 [95% CI 0.88–0.99]). The Clinical Frailty Scale had the best performance of the non-physical assessment frailty screening methods (AUC 0.90 [95% CI 0.84–0.97], sensitivity 0.79 [95% CI 0.57–0.91], specificity 0.87 [95% CI 0.78–0.93]). Conclusions: Walking speed can be used to accurately screen for frailty in CKD populations. If it is not practical to perform a physical assessment to screen for frailty, the Clinical Frailty Scale is a useful alternative.

Background and aims: self-poisoning accounts for a substantial proportion of acute medical hospital presentations, but has been poorly characterised in older adults. This study sought to determine the agents ingested by older adults presenting to hospital after drug overdose, and to compare clinical outcomes to younger patients. Methods: a retrospective observational study of patients admitted via the emergency department due to drug overdose between 2004 and 2007. Results: during the study period, there were 8,059 admissions, including 4,632 women (57.5%). This included a subgroup of 361 patients (4.5%) who were >60 years of age. This subgroup was more likely to require hospital stay >1 night, odds ratio (95% confidence interval) = 4.3 (3.6–5.5, P < 0.0001), transfer to a critical care area = 3.8 (1.1–13.0, P = 0.0340) and had higher mortality = 4.8 (1.1–22.1, P = 0.0463). A higher proportion of older patients required transfer to a psychiatric unit (P < 0.0001) or to a general medical ward (P < 0.0001) than younger adults. Conclusions: older adults that presented to hospital after drug overdose had ingested different drugs than younger patients, possibly due to different prescribing patterns, and had a poorer outcome. The use of drugs associated with significant toxicity should be avoided in older patients at risk of self-harm.