Recommendations for the management of frailty in chronic kidney disease: a consensus report

Frailty is highly prevalent in patients with chronic kidney disease (CKD) and is associated with increased mortality, hospitalization and disability and with poorer quality of life. Despite its prognostic importance, substantial knowledge gaps remain with regard to the optimal tools for assessing frailty in CKD settings, the extent to which frailty can be reversed through targeted interventions, and how frailty should inform decision-making between conservative kidney management and kidney replacement therapy (KRT). This consensus report provides 63 consensus statements across four domains covering the assessment of frailty, interventions aimed at targeting the modifiable contributors to frailty in patients with CKD, considerations related to conservative kidney management and KRT, and the management of stage 5 CKD in the presence of frailty. Key recommendations include the need for routine frailty screening using multi-dimensional tools; the implementation of interventions to target physical activity with a focus on resistance training, adequate dietary protein intake, medication optimization and comprehensive geriatric assessment; a frailty-informed, person-centred framework for shared decision-making that emphasizes transparent communication, goal elicitation and cultural safety; and flexible KRT delivery - including less intensive dialysis schedules, assisted home dialysis and transplant eligibility assessment - guided by serial frailty measurement. The report concludes with priority research questions and a patient partner's reflections on the co-production of consensus statements.