Epsom and St Helier University Hospitals NHS Trust

Aims Performance indicators are increasingly used to evaluate the quality of healthcare provided to patients with a hip fracture. The aim of this review was to map the variety of performance indicators used around the world and how they are defined. Methods We present a mixed methods systematic review of literature on the use of performance indicators in hip fracture care. Evidence was searched through 12 electronic databases and other sources. A Mixed Methods Appraisal Tool was used to assess methodological quality of studies meeting the inclusion criteria. A protocol for a suite of related systematic reviews was registered at PROSPERO (CRD42023417515). Results A total 24,634 articles were reviewed, of which 171 met the criteria of the review. Included studies were heterogenous in design and came from varied healthcare systems in 34 different countries. Most studies were conducted in high-income countries in Europe (n = 118), followed by North America (n = 33), Asia (n = 21), Australia (n = 10), and South America (n = 2). The highest number of studies in one country came from the UK (n = 45). Only seven of the 171 studies (< 2,000 participants) were conducted across ten low- and middle-income countries (LMICs). There was variation in the performance indicators reported from different healthcare systems, and indicators were often undefined or ambiguously defined. For example, there were multiple definitions of 'early' in terms of surgery, different or missing definitions of ‘mobilization’, and variety in what was included in an ‘orthogeriatric assessment’ in hip fracture care. However, several performance indicators appeared commonly, including time to surgery (n = 142/171; 83%), orthogeriatric review (n = 30; 17%), early mobilization after surgery (n = 58; 34%), and bone health assessment (n = 41; 24%). Qualitative studies (n = 18), mainly from high-income countries and India, provided evidence on the experiences of 192 patients and 138 healthcare professionals with regard to the use of performance indicators in clinical care and rehabilitation pathways. Themes included the importance of education and training in parallel with the introduction of performance indicators, clarity of roles with the clinical team, and the need for restructuring or integration of care pathways. Conclusion This review identified a large number of performance indicators related to the delivery of healthcare for patients with a hip fracture. However, their definitions and thresholds varied across studies and countries. Evidence from LMICs is sparse. Both qualitative and quantitative evidence indicates that there remains a pressing need for further research into the use and standardization of performance indicators in hip fracture care and their influence on patient outcomes and economic costs. Cite this article: Bone Jt Open 2025;6(3):275–290.

Objective To assess obstetric outcomes in pregnant women with ‘reactive hypoglycaemia’ (RH) during an oral glucose tolerance test (OGTT), defined as a 2‐h blood glucose level lower than the fasting value. Design Retrospective observational study. Setting Two tertiary maternity units in the United Kingdom. Population A total of 1498 women with singleton pregnancies attending for an OGTT between April 2019 and July 2020. Methods Maternal and neonatal outcomes were compared between three groups: gestational diabetes, reactive hypoglycaemia and normal OGTT. Both logistic and linear regression models were used, which adjusted for maternal age at booking, ethnicity, parity and BMI. Main Outcome Measures Abdominal circumference > 95th centile, polyhydramnios, gestational age at delivery, preterm birth, birthweight, neonatal hypoglycaemia, admission to neonatal unit, perinatal mortality. Results Of the 1498 women, 26.7% (n = 400) had reactive hypoglycaemia, 27.8% (n = 417) GDM and 45.4% (n = 681) normal GTT. The reactive hypoglycaemia group were twice as likely to develop polyhydramnios compared with both the GDM (OR 2.77, 95% CI 1.40–5.50) and control groups (OR 2.47, 95% CI 1.31–4.65). Relative to those with GDM, women with reactive hypoglycaemia had a similar mean birthweight (mean difference 59.4 g, p = 0.06) but were less likely to experience neonatal hypoglycaemia (OR 0.30, 95% CI 0.001–0.15) or preterm birth (OR 0.33, 95% CI 0.18–0.60). No differences were found in maternal hypertensive disorders, abdominal circumference > 95th centile, shoulder dystocia, Apgar < 7, cord pH, admission to neonatal unit or perinatal mortality. Conclusion Women with reactive hypoglycaemia in this sample were at risk of adverse outcomes frequently associated with diabetes, including polyhydramnios.

The classification and treatment of myocardial infarction (MI) have evolved significantly over the past few decades, with the ST-segment elevation myocardial infarction (STEMI)/non-STEMI (NSTEMI) paradigm dominating clinical practice. While STEMI, identified by ST-segment elevation (STE) on electrocardiogram (ECG), has been the hallmark for urgent reperfusion therapy, this model misses a substantial number of patients with occlusive myocardial infarction (OMI) who do not exhibit STE. Recent evidence reveals that up to 25% of NSTEMI patients have OMI, leading to higher mortality due to delayed reperfusion. The emerging OMI/NOMI (Occlusive vs. Non-Occlusive MI) paradigm offers a more nuanced approach, incorporating advanced ECG interpretation and tools like point-of-care echocardiography and artificial intelligence (AI). AI has shown promise in detecting subtle ECG changes indicative of OMI, improving diagnostic accuracy and reducing misdiagnosis. This paradigm shift has important implications for clinical practice, calling for earlier identification of OMI and more inclusive treatment strategies to enhance patient outcomes.

People with type 2 diabetes are at risk of developing progressive diabetic kidney disease (DKD) and end stage kidney failure. Hypertension is a major, reversible risk factor in people with diabetes for development of albuminuria, impaired kidney function, end-stage kidney disease and cardiovascular disease. Slowing progression of kidney disease and reducing cardiovascular events can be achieved by a number of means including the targeting of blood pressure and the use of specific classes of drugs The use of Renin Angiotensin Aldosterone System (RAAS) blockade is effective in preventing or slowing progression of DKD and reducing cardiovascular events in people with type 2 diabetes, albeit differently according to the stage of DKD. However, emerging therapy such as non-steroidal selective mineralocorticoid antagonists (finerenone) is proven to lower blood pressure and further reduce the risk of progression of DKD and cardiovascular disease in people with type 2 diabetes. This consensus reviews current evidence and make recommendations for the use of finerenone in the management of diabetes kidney disease in the UK.

Aims The Heart Failure Frailty Score (HFFS) is a novel, multidimensional tool to assess frailty in patients with heart failure (HF). It has been developed to overcome limitations of existing frailty assessment tools while being practical for clinical use. The HFFS reflects the concept of frailty as a multidimensional, dynamic and potentially reversible state, which increases vulnerability to stressors and risk of poor outcomes in patients with HF. Methods and results The HFFS was developed through a Delphi consensus process involving 54 international experts. This approach involved iterative rounds of questionnaires and interviews, where a panel of experts provided their opinions on specific questions prepared by the Steering Committee. The experts were invited to vote and share their views anonymously, using a 5‐point Likert scale over iterative rounds. An 80% threshold was set for agreement or disagreement for each statement. Twenty‐two variables from four domains (clinical, functional, psycho‐cognitive and social) have been selected for inclusion in the HFFS after the third round of the Delphi process. A shorter version (S‐HFFS), including 10 variables, has also been developed for daily clinical use. Conclusions The HFFS is a new multidimensional tool for the identification of frailty in patients with HF. It should also enables healthcare providers to identify potential ‘red flags’ for frailty in order to develop personalized care plans. The next step will be to validate the new score in patients with HF.

Physicians of old have long recognised the importance of biological material for diagnostic purposes. One such example being the recognition of blood in faeces and the possibility of significant disease. This has since led to the development of stool testing for the detection of blood, from chemical-based reactions (guaiac reduction-based test) through to antigen–antibody interactions such as the faecal immunochemical testing (FIT). FIT has proven to be robust in terms of the evidence around its preanalytical and analytical use. As with any test however, when applied in a heterogenous population, its performance can be variable. Nonetheless, its accuracy for the detection of colorectal cancer, in both the screening and symptomatic population, appears consistent and acceptable as a triage tool—which is impressive. There are clinical dilemmas in the utility of FIT; for example, use in iron deficiency anaemia, variation of threshold within screening population, utility in high-risk and low-risk populations, replicate and repeat testing and FIT above threshold with normal colonoscopy. The evidence base remains unclear, and some are conflicting; hence, no clear guidance can be proffered, save clinical judgment. Combination therapy—with other markers—holds promise and its use within a reconfigured clinical pathway, attention to health inequalities, coupled with robust cost-utility analysis will ensure that FIT (alone and/or in combination with other markers) can continue to have a role—more so in the community.

Introduction Pre-eclampsia is a condition associated with significant maternal and neonatal morbidity and mortality. The prediction of pre-eclampsia in high-risk populations using angiogenic markers, such as serum placental growth factor (PlGF) assessment, has been shown to improve maternal outcomes and is recommended by the National Institute for Health and Care Excellence (NICE). However, such tests are not yet available at the point of care (POC). Glycosylated fibronectin (GlyFn) level for the prediction of pre-eclampsia development is available as a POC test (Lumella) and has the potential to aid rapid clinical decision making. This study aimed to test the hypothesis that the sensitivity of the GlyFn test is not inferior to that of the current gold standard of soluble fms-like tyrosine kinase (sFlt)/PlGF-based laboratory testing for pre-eclampsia. Methods and analysis This is a multicentre prospective study. Women at risk for pre-eclampsia based on predefined clinical and/or obstetric risk factors will be invited to participate in the study. The recruitment target is 400 participants. Consenting participants will have paired samples for sFlt/PlGF together with POC GlyFn testing. Two follow-up visits are planned at 2 and 4 weeks after the initial recruitment where repeat testing with both tests will be performed. The clinical team will be blinded to the results of the GlyFn test but not that of the sFlt/PlGF test. Clinical care will be based on established protocols incorporating maternal/fetal evaluation and the results of sFlt/PlGF levels. Maternal and neonatal outcome data will be collected to compare the sensitivity and specificity of the tests, with the primary outcome being delivery for pre-eclampsia within 4 weeks. Ethics and dissemination Ethical approval has been obtained from the Health Research Authority and Health and Care Research Wales Ethics Committee. The results of this study will be published in peer-reviewed journals and presented at scientific conferences. Trial registration number ISRCTN13430018

Aims Older adults with hip fractures are at high risk of experiencing complications after surgery, but estimates of the rate of specific complications vary by study design and follow-up period. The aim of this systematic review was to determine the prevalence of complications in older adults after hip fracture surgery. Methods MEDLINE, Embase, CINAHL, and CENTRAL databases were searched from inception until 30 June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (aged ≥ 60 years) undergoing hip fracture surgery. Results A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications, the 30-day prevalence of reoperation was 2.31%, surgical site infection 1.69%, and deep surgical site infection 0.98%; the 365-day prevalence of prosthesis dislocation was 1.11%, fixation failure 1.77%, and periprosthetic or peri-implant fracture 2.23%. For general complications, the 30-day prevalence of acute kidney injury was 1.21%, blood transfusion 25.55%, cerebrovascular accident 0.79%, lower respiratory tract infection 4.08%, myocardial infarction 1.98%, urinary tract infection 7.01%, and venous thromboembolism 2.15%. Conclusion Complications are prevalent in older adults who have had surgery for a hip fracture. Studies reporting complications after hip fracture surgery varied widely in terms of quality, and we advocate for the routine monitoring of complications in registries and clinical trials to improve the quality of evidence. Cite this article: Bone Joint J 2025;107-B(2):139–148.

In a rapidly evolving healthcare environment, artificial intelligence (AI) is transforming diagnostic techniques and personalised medicine. This is also seen in osseous biopsies. AI applications in radiomics, histopathology, predictive modelling, biopsy navigation, and interdisciplinary communication are reshaping how bone biopsies are conducted and interpreted. We provide a brief review of AI in image- guided biopsy of bone tumours (primary and secondary) and specimen handling, in the era of personalised medicine. This paper explores AI’s role in enhancing diagnostic accuracy, improving safety in biopsies, and enabling more precise targeting in bone lesion biopsies, ultimately contributing to better patient outcomes in personalised medicine. We dive into various AI technologies applied to osseous biopsies, such as traditional machine learning, deep learning, radiomics, simulation and generative models. We explore their roles in tumour board meetings, communication between clinicians, radiologists, and pathologists. Additionally, we inspect ethical considerations associated with the integration of AI in bone biopsy procedures, technical limitations, and we delve into health equity, generalisability, deployment issues, and reimbursement challenges in AI-powered healthcare. Finally, we explore potential future developments and offer a list of open-source AI tools and algorithms relevant to bone biopsies, which we include to encourage further discussion and research.

Objectives Predicting longer term response to biological therapy for small bowel Crohn’s disease (SBCD) is an unmet clinical need. Diffusion-weighted MR imaging (DWI) may indicate disease activity, but its predictive ability, if any, is unknown. We investigated the prognostic value of DWI for one year response or remission (RoR) in SBCD patients commencing biologic therapy, including incremental value over C-reactive protein (CRP) and faecal calprotectin (FC). Methods A subset of participants in a prospective, multicentre study investigating the predictive ability of motility MRI for one-year RoR in patients starting biologic therapy for active SBCD, underwent additional DWI at baseline and post-induction (12-30 weeks). CRP and FC were collected in a subgroup. RoR at one year was evaluated using clinical and morphological MRE parameters. We calculated sensitivity and specificity to predict RoR and Quality of life (QoL) at one year, comparing apparent diffusion coefficient (ADC) value, Clermont score and CRP using multivariable logistic regression. Results 25 participants were included (mean 36.9 years, 32% female). ADC changes and Clermont score had poor sensitivity (30.0% [95%CI: 6.7-65.2] and 40.0% [95%CI: 12.2-73.8] respectively) and poor-to-modest specificity (50.0 [95%CI: 27.2-72.8] and 65.0% [95%CI: 40.8-84.6]) for RoR. None of Clermont score, CRP or FC predicted QoL. Conclusions DWI has inadequate sensitivity and specificity for RoR at one year. There is no significant incremental prognostic value of DWI over CRP and FC to predict RoR and/or QoL at one year. Advances in knowledge Early post-induction DWI has no prognostic value for RoR at one year.

Purpose: This study aimed to evaluate the effectiveness of integrating image data and metadata in glaucoma detection using AI. Early detection is crucial in preventing vision loss, hence the focus on enhancing diagnosis accuracy by combining image features with patient metadata like age, gender, and ocular measurements. Methods : We used a dataset of 331 images from the PAPILA database, split into normal (298) and glaucoma (33) classes. Initially, the EfficientNetV2B0 model was trained solely on image data. Subsequently, patient metadata such as age, gender, pachymetry, refractive error, and axial length were incorporated. The dataset was split 70% for training, 15% for validation, and 15% for testing. Results : Training with image data alone yielded a 79% AUC on the test set, indicating moderate performance. Integrating patient metadata improved the AUC to 83%, slightly enhancing diagnostic accuracy. However, statistical analysis using the De Long Test showed no significant difference between the two models, suggesting limited improvement from metadata integration. Conclusion : This study highlights the potential of integrating patient metadata with image data for glaucoma detection using AI. References Kovalyk O, Morales‐Sánchez J, Verdú‐Monedero R, Sellés‐Navarro I, Palazón‐Cabanes A, Sancho‐Gómez JL. PAPILA: Dataset with fundus images and clinical data of both eyes of the same patient for glaucoma assessment. Sci Data. 2022 Jun 9;9(1):291. doi: 10.1038/s41597‐022‐01388‐1. PMID: 35680965; PMCID: PMC9184612.

Aims/Purpose : This study aimed to explore the feasibility of predicting intraocular pressure (IOP) using a neural network model incorporating both image data and patient metadata. The objective was to evaluate the potential of this approach in improving the understanding and prediction of IOP levels in individuals, utilizing data from the PAPILA public database. Methods : We employed a dataset containing 331 images from the PAPILA database, with 298 images classified as normal and 33 diagnosed with glaucoma. Additionally, patient metadata such as glaucoma diagnosis status, age, sex, refractive defect, pachymetry, and axial length were incorporated. The dataset was divided into 70% for training the neural network model, 15% for validation, and 15% for testing. Results : The analysis of the neural network model's predictive performance produced the following metrics: Mean Absolute Error (MAE) of 2.515, Root Mean Square Error (RMSE) of 3.131, and Mean Absolute Percentage Error (MAPE) of 16.611%. These results indicate a moderate level of predictive capability for IOP based on the input data. Conclusions : In conclusion, our study demonstrates promising potential in utilizing artificial intelligence to predict intraocular pressure (IOP) using image data and patient metadata. While our model's predictive performance is moderate, it sets the stage for further advancements. With continued refinement and exploration of additional factors, AI‐driven approaches hold promise for revolutionizing glaucoma management. References Kovalyk O, Morales‐Sánchez J, Verdú‐Monedero R, Sellés‐Navarro I, Palazón‐Cabanes A, Sancho‐Gómez JL. PAPILA: Dataset with fundus images and clinical data of both eyes of the same patient for glaucoma assessment. Sci Data. 2022 Jun 9;9(1):291. doi: 10.1038/s41597‐022‐01388‐1. PMID: 35680965; PMCID: PMC9184612.

Purpose : This study aimed to assess an artificial intelligence (AI) model's performance in glaucoma detection using the RIM One public database. Specifically, we examined the impact of considering only high‐confidence predictions from the AI model on overall diagnostic accuracy. Methods : The RIM One database provided 485 images, including 313 normal and 172 glaucomatous cases. Of these, 248 images were for training the EfficientNetV2B0 model, 63 for validation, and 174 for testing. Initially, the model's performance was evaluated on the entire test set, yielding an AUC of 96%. Subsequently, we investigated the model's performance when limiting predictions to those with a certainty probability over 95%, reducing the test set to 155 images. Results : The AI model achieved an AUC of 96% when considering all predictions. However, focusing solely on high‐confidence predictions ( > 95% certainty) increased the AUC to 100%. This adjustment reduced the test set size from 174 to 155 images. Statistical analysis using the De Long Test revealed a significant difference between the two AUC values, highlighting the efficacy of high‐confidence predictions. Conclusion : Our findings demonstrate that by considering only AI predictions with a certainty probability exceeding 95%, we can significantly enhance glaucoma detection's diagnostic accuracy. This approach resulted in a perfect AUC, indicating robust performance in identifying glaucomatous cases. The reduction in test set size suggests that 19 cases may require further evaluation through methods such as visual field testing or optical coherence tomography (OCT) to confirm or exclude the diagnosis of glaucoma. This selective approach not only improves the efficiency of glaucoma diagnosis but also streamlines clinical decision‐making by directing resources to cases with the highest predictive certainty.

A young lady was brought to the hospital by the police after they found her wandering in the streets far away from her home behaving oddly. At admission, she was confused and had various delusional thoughts accompanied by visual and auditory hallucinations. After she was identified and her old medical notes were retrieved, it was found that she had a diagnosis of systemic lupus erythematosus (SLE) previously for which she declined any treatment. MRI brain, CSF results and EEG were unremarkable. Laboratory results confirmed the diagnosis of SLE with low disease activity. Anti-RNP antibodies were positive alongside other common markers of SLE, which pointed towards a rare entity called lupus psychosis. She was started on immunosuppression with methylprednisolone and cyclophosphamide combined with antipsychotics. Following treatment, she improved significantly and is currently leading a normal life.

Cite this article: Bone Joint Res 2025;14(1):16–19.

Objective Evaluate the role of surgery as the sole treatment modality for patients with cervical head and neck squamous cell carcinoma of unknown primary (HNSCCUP). Design Systematic review of observational cohort studies with qualitative synthesis. Setting PubMed, Ovid EMBASE, and Cochrane Controlled register of Trials (CENTRAL) were screened from January 2000 up to October 2021. Participants Patients with HNSCCUP after completing diagnostic workup subsequently treated with single‐modality surgery. Main Outcome Measures The primary outcome was 3‐year overall survival (OS). Secondary outcomes included disease‐free survival (DFS), primary emergence, regional recurrence, and distant metastasis. Results Fourteen eligible studies were identified, including 1780 patients, of whom 294 received surgery as their sole treatment (seven studies) with 3‐year OS ranging from 43.9% to 100%. 3‐year DFS was reported in four studies ( n = 62) ranging from 42.8% to 67.0%. 5‐year OS and DFS were available in three studies ( n = 31), ranging from 36.6% to 75.0%, and 43.6% to 67.0%, respectively. The rate of primary emergence ranged from 11.1% to 33.3% (seven studies, n = 157), regional relapse from 0.0% to 50.0% (five studies, n = 60) and distant metastasis from 0.0% to 3.3% (three studies, n = 45). Patients undergoing surgery as a sole treatment had predominantly p16/HPV positive N1 (TNM7) disease without ECS. Conclusion Outcomes for HNSCCUP patients undergoing surgery alone range widely in the literature but may be reasonable in a subset of patients with early‐stage p16/HPV positive disease. Data is lacking for p16/HPV negative disease where the potential primary site is more varied and primary emergence appears more common.

In response to increased focus on the issue of Assisted Dying (AD) in the UK due to the presentation of The Terminally Ill Adults (End of Life) Bill 2024–25 [1] and bills before parliaments in the Isle of Man, Guernsey and Scotland, the British Geriatrics Society (BGS) recently developed a position statement opposing legalisation of AD in the UK [2]. We set out our key reasoning behind this position, namely the current adverse health and social care context and significant concern about whether effective safeguards can be created to protect older people with complex needs from undue harms. The BGS asks for improved, personalised, multidisciplinary care for older people at the end of their lives, including high-quality palliative and end-of-life care. It urges caution about legalisation and offers its expertise in any potential future shaping and implementation of AD legislation. This should include a conscience clause for professionals objecting to direct involvement. The main outcomes from a survey of member’s opinions are also outlined [2]. The majority were against legalisation of AD; however, a significant minority were in favour, with some undecided. This diversity of opinion highlights a need for the Society to maintain balance and nuance on this difficult and emotive issue, warranting future BGS reviews if the relevant legislation changes.

Background Acquired angioedema due to C1-inhibitor deficiency (AAE-C1-INH) is very rare compared to its prototype, hereditary angioedema. An updated characterisation of the AAE-C1-INH cohort in UK is required to inform management. Objectives To describe the disease burden of AAE-C1-INH, long-term prophylaxis (LTP) and the clinical, immunochemical and treatment profiles of AAE-associated diseases in UK. Method Retrospective data on 117 AAE-C1-INH patients were collected using a national survey proforma across 25/34 Adult Clinical Immunology and Allergy centres in UK. Other European cohorts were compared. Results Median age at AAE-C1-INH diagnosis was 65 years with 3.4% of patients diagnosed below 40 years. The median delay in diagnosis was one year. Antifibrinolytics and attenuated androgens showed comparable efficacy as LTP 88.9% and 89.5%, respectively. A haematological disorder was identified in 83.8% AAE-C1-INH patients compared to 3.4% autoimmune diseases. The predominant haematological disorders were splenic marginal zone lymphoma (SZL) 34% followed by MGUS 16%. The severity of angioedema did not depend on the associated disease. Anti-C1INH-autoantibodies testing was limited at 23.1%. Rituximab monotherapy was effective in treating 9/9 SZL and 1/2 MGUS-associated AAE-C1-INH. Rituximab efficacy was independent of anti-C1INH-autoantibodies detection with response in 3/3 seronegative and 4/4 seropositive patients Conclusion The diagnosis of AAE-C1-INH should not be overlooked below the age of 40 years. The choice of oral LTP should be informed by propensity to side-effects. B-cell depletion could be considered in treating monoclonal B cell disorder-associated-AAE-C1-INH in the absence of haematological indications. Further studies are required to address the clinical utility of anti-C1INH-autoantibodies.

Background Non-anaemic iron deficiency is highly prevalent in people living with chronic kidney disease (CKD) but is underdiagnosed and undertreated, especially in earlier stages of CKD. A multicentre trial assessing the effect of intravenous iron supplementation in iron-deficiency but not anaemic people with CKD included a qualitative sub-study which aimed to explore the patient experience and psychosocial impact of living with CKD and iron deficiency, and the experience of the therapeutic intervention (intravenous iron and exercise). Methods Semi-structured interviews were conducted with 23 trial participants blinded to treatment. Topics explored included experiences of living with CKD and iron deficiency, symptoms, social and leisure activities, quality of life, and participants’ views and experiences of receiving the therapeutic intervention. Thematic analysis was used to identify and report themes. Results Six overarching themes were identified: lack of awareness of iron deficiency; overwhelming feelings of tiredness; feeling limited; balancing emotions; perceptions and experiences of therapeutic treatment received; and impact of trial participation on life participation. Trial participation, specifically the exercise training, was perceived to be beneficial, with improvements in life participation and psychological well-being experienced. However, there were no clear differences between treatment groups, with mixed perceptions about which therapeutic treatment was received. Conclusions The impact of tiredness on individuals with CKD is profound and can result in reduced vitality, impaired ability to engage in life activities, and emotional conflict. Improved communication and support about psychosocial impact and management of symptoms, particularly fatigue, for people with CKD may be required, alongside effective therapeutic interventions, to improve symptom management and quality of life.