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An introducton to the KHA-CARI guidelines.

Learning objectves

* To understand the imperative for using clinical guidelines, and the reasons why they have the potential to improve health care delivery.

* To identify international nephrology organisations who formulate guideline recommendations related to kidney disease.

* To appreciate the significance of differing evidence levels and grades as they relate to guideline recommendations.

* To develop an ongoing working knowledge of KHA-CARI guidelines and updates.

What are guidelines and why are they necessary?

Clinicians caring for people with kidney disease make frequent decisions about the best treatment option for delivering that health care. Every day more research is published contributing to the body of knowledge about the best way to provide care. It is impossible for each care-provider to review all of the literature and hence there is a risk of choosing a treatment based on past experience; a biased and possibly an out-of-date choice. Guidelines, which are basically a summary of recommendations for care, help to overcome this risk of bias and potentiate evidence-based practice, the gold standard for best outcomes. It is always important to remember, however, that clinician expertise and individual patient needs will always remain part of that decision-making process. The KHA-CARI Steering Committee is committed to developing reliable and trustworthy guidelines that follow practice recommendations from the best available evidence, with a high degree of transparency through all aspects of the process.

"Guidelines are sets of non-mandatory rules, principles or recommendations for procedures or practices in a particular field" (NHMRC, 2017, p. 1), which only become mandatory if adopted as policy, legislation or as codes of conduct. Various governmental agencies, (national and international) offer advice on the formulation and utilisation of guidelines.

In Australia, the National Health, Medical and Research Council (NHMRC) is the expert body responsible for the regulation of public and individual health care standards. They suggest Australian health care organisations ensure that guidelines meet international standards, and amongst other considerations guidelines should:

* be relevant to the population they represent, with respect to cultural, local, regional, and national specifications

* clearly state the purpose and context

* ethically reflect the community's range of attitudes and concerns

* be well informed by research evidence and subject to peer review

* address the health care issue at hand

* have a clearly stated purpose

* be feasible to implement (NHMRC, 2017).

Specifically, KHA-CARI add that guidelines need to:

* enhance the appropriateness, consistency and cost-effectiveness of renal health care

* be reliable and trustworthy

* arise from current and appropriate research

* improve outcomes through improved quality of care for consumers

* improve benefits for health care providers

* minimise risk of harm

* bring about positive change (Howell, 2015).

What are evidence levels and grades?

Guidelines are strictly derived from evidence-based, published research literature. Evaluation and grading of the evidence is necessary to ensure quality and appropriateness for the findings to be applicable to clinical practice (NHMRC, 2017; Howell, 2015).

The evidence level or grade of evidence is an alphabetical or numerical value ascribed to a piece of information that intends to describe the overall quality of that evidence. Different grades have different recommendation strengths: Level 1: "we recommend...", and Level 2: "we suggest...". The evidence levels have specific, yet linked, implications for the patient, clinician and policy stakeholders. The higher or stronger levels of recommendation are based on the level of the evidence, which at the highest is based on randomised controlled trials and at the lowest is based on expert opinion. For example, the NHMRC Evidence Hierarchy designates levels of evidence according to the type of research question, in six evidence levels (NHMRC, 2009). This is similar to the Joanna Briggs Institute levels of evidence for effectiveness, which displays five levels of evidence for effectiveness in diagrammatical format (Joanna Briggs Institute, 2014). Over the past few decades, various scientific agencies have made recommendations regarding sourcing of the most appropriate quality of evidence for the research question, and these are similarly aligned.

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a working group which suggests use of their internationally recognised approach to rate the quality of evidence and the strength of recommendations. GRADE is considered to be the standard in guideline development (NHMRC, 2017) and this approach is utilised in the KHA-CARI guidelines (Howell, 2015). Evidence levels and grades are given within each KHA-CARI guideline.

KHA-CARI guidelines

* Are accessible through the KHA-CARI website at

* Writing of Kidney Health Australia (KHA)--Caring for Australasians with Renal Impairment (CARI) Guidelines were commenced in the 1990s, and the process is ongoing.

* Mission statement: "KHA-CARI Guidelines seek to improve the quality of care and outcomes for patients with kidney disease in Australia and New Zealand by facilitating the development and implementation of clinical practice guidelines based on the best available evidence and effectiveness." (KHA-CARI, 2017, p. 1).

* It is envisaged that they be the front-line resource for Australasian clinicians and consumers in considering care options for persons with kidney disease.

* New guideline commentary and updates are frequently published in the journal Nephrology.

* Current KHA-CARI guidelines are sectioned into three areas, with subsections and dates:
* Chronic kidney disease guidelines
 ** Acute kidney injury                            May 2014
 ** Cardiovascular disease                         May 2013
 ** Diagnosis and treatment of                     Nov 2014
    urinary tract infection in children
 ** Early chronic kidney disease                   May 2013
 ** Nutrition and growth in kidney disease         Dec 2005
 ** Vitamin D, calcimimetics & P[O.sub.4] binders  Apr 2006
* Dialysis guidelines
 ** Biochemical and haematological targets         Jul 2013
 ** Dialysis adequacy                              Apr 2013
 ** Peritonitis treatment and prophylaxis          Jan 2014
 ** Vascular access                                Jun 2012
* Transplantation guidelines
 ** Care of kidney transplant recipients           Jan 2012
 ** CMV disease                                    Mar 2011
 ** Recipient assessment for transplantation       Mar 2013

* Archived guidelines:

There is an extensive list of guidelines from each of the three areas, which are out of date and have been archived to an accessible link on the website. Guidelines may be considered out of date if older than five years, but in some areas there is little new research, meaning a guideline may stay relevant for longer than this arbitrary period. The KHA-CARI steering committee oversees writing and updating of the guidelines, and decides if a guideline remains current or should be archived. Of note, some archived guidelines contain relevant information, but may have been archived because another guideline group has produced a more recent guideline.

* Guideline structure and content:

Individual guidelines are constructed of several sections (subtopics), to offer a sectioned, comprehensive and transparent overview of the evidence, as follows:

--Guideline section title


--Guideline summary

--Ungraded suggestions for clinical care

--Implementations and audit


--Search strategy

--Overview of the evidence

--Comment on what other guidelines say

--Suggestions for further research

--Conflict of interest


Which other international guidelines focus on persons with kidney disease?

* In parallel with most international health commentary, as directed by the World Health Organization (WHO), guidelines frequently link in, or take into account those written by other international authorities. The KHA-CARI guidelines make reference to these organisations within the guideline commentary.

* United States: The National Kidney Foundation (NKF) began developing guidelines which were published in 1997 as Dialysis Outcome Quality Initiative (DOQI). Since then, with other international nephrology specialist collaboration and commentary (Eknoyan et al., 2004), these have been further developed and now comprise 13 guidelines, under the auspices of the Kidney Disease Outcomes Quality Initiative (KDOQI). NKF publishes a list of topics under either chronic kidney disease or dialysis care (NKF, 2017). Their new guideline commentary and updates are frequently published in the American Journal of Medicine, Journal of American Society of Nephrologists, and American Journal of Kidney Disease.

* Europe: In 1999, the European Renal Association and European Dialysis and Transplant Association (ERA-EDTA) initiated the European Best Practice Guidelines (EBPG). In 2008, after a change in philosophy, these were adapted from "guidelines" to "recommendations" or "position statements" under the new term European Renal Best Practice (ERBP) (ERA-EDTA, 2017). Their new guideline commentaries and updates are frequently published in the journal, Nephrology Dialysis Transplantation.

* United Kingdom: The Renal Association (RA), founded in 1950, has contrived a list of 10 guidelines to date, covering care aspects of kidney disease, formulated into their Renal Association's Clinical Practice Guidelines, as accredited by the National Institute for Health and Care Excellence (NICE) (Renal Association). They are informally allied with the British Association for Paediatric Nephrology (BAPN). Their new guideline commentaries and updates are published on their website.

* Canada: In 2008, the Canadian Society of Nephrology developed their guidelines which cover approximately ten areas of nephrology care. Specifically these align with guidelines as recommended by their national hypertension, cardiology and diabetes associations (Levin et al., 2008). Their new guideline commentaries and updates are frequently published in the Canadian Medical Association Journal.


Eknoyan, G., Lameire, N., Barsoum, R., Eckardt, K., Levin, A., Levin, N., Locatelli, F., MacLeod, A., Vanholder, R., Walker, R., & Wang, H. (2004). 'The burden of kidney disease: Improving global outcomes. Kidney International, 66, 1310-4.

ERA-EDTA 2017, European Renal Best Practice, ERBP 2017.

Howell, M. (2015). KHA-CARI guidelines development manual, KHA-CARI Guidelines Office, Centre for Kidney Research 2017.

Joanna Briggs Institute (JBI). (2014). New JBI Levels of Evidence. The University of Adelaide.

KHA-CARI. (2017). Caring for Australasians with Renal Impairment, KHA-CARI 2017.

Levin, A., Hemmelgarn, B., Culleton, B., Tobe, S., McFarlane, P. , Ruzicka, M., Burns, K., Manns, B., White, C., Madore, F. , Moist, L., Klarenbach, S., Barrett, B., Foley R., Jindal, K., Senior, S., Pannu, N., Shurraw, S., Akbari, A., Cohn, A., Reslerova, M., Deved, V. , Mendelssohn, M., Nesrallah, G., Kappel, J., & Tonelli, M. (2008). Guidelines for the management of chronic kidney disease. Canadian Medical Association Journal, 179(11), 1154-62.

National Health and Medical Research Centre (NHMRC). (2009). NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Canberra: Australian Government 2017.

National Health and Medical Research Centre (NHMRC). (2017). Information for Guideline Developers, by NHMRC. Australian Government.

National Kidney Foundation (NKF). (2017). Guidelines and commentaries, NKF 2017.

Renal Association. (2013). The Renal Association, RA 2017.

Wendi Bradshaw, RN, MN, Monash Health, VIC, Australia

Debbie Fortnum, RN, MN, Sir Charles Gairdner Hospital, WA, Australia

Correspondence to: Wendi Bradshaw, Dandenong Dialysis Unit, Monash Health, Dandenong, VIC 3175, Australia


Submitted: 29 August 2017, Accepted: 6 October 2017

For further informaton:

KHA-CARI Guidelines:

For detailed information on the KHA-CARI guideline development and writing process, including evidence level

and grading descriptions:

European Renal Best Practice (ERBP):

Kidney Disease Improving Global Outcomes (KDIGO:

National Institute of Health and Care Excellence (NICE):

Information about the GRADE approach:
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Author:Bradshaw, Wendi; Fortnum, Debbie
Publication:Renal Society of Australasia Journal
Date:Nov 1, 2017
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