Background
Methods
Search strategy
Guideline portals
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Guidelines-International-Network (G-I-N) [www.g-i-n.net].
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NHS Centre for Reviews and Dissemination (CRD) [19]
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National guideline Clearinghouse [10]
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Haute Autorité de Santé (HAS) [20]
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Ärztliches Zentrum für Qualität in der Medizin (AEZQ) [21]
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Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (common working group of scientific medical Specialty Associations, AWMF) [www.awmf.org]
Database
Google search
Manual search
Selection of guidelines
Inclusion criteria | Excluson criteria: |
---|---|
guideline issued in an industrialized country | relevance limited to subspecialty or subtheme |
guideline is relevant to management of patients with CKD | relevance is limited to acute renal insufficiency |
guideline is targeted to adult patients | target group of children |
guideline is available in one of the following languages: Dutch/Flemish, English, French, German | relevance is limited to pregnancy or childbirth |
guideline is relevant to ambulatory patients | relevance is limited to KDIGO stage 4 and above |
relevance is limited to patients on dialysis | |
relevance is limited to kidney transplant patients | |
relevance is limited to inpatients |
Quality assessment
Data extraction
Results
Selection of guidelines
country | Issueing organization | name of guideline | initial release | revisions | target patients | target users/setting | evidence base | grading of evidence | ||
---|---|---|---|---|---|---|---|---|---|---|
LoE | GoR | |||||||||
CEBAM | Belgium | Belgian Centre for Evidence Based Medici, Cochrane Belgium | Chronische Niereninsufficiëntie | 2012 | adult patients (over 18 years of age) with chronically diminished kidney function | general practitioners | systematic guideline review, additional systematic searches | GRADE | ||
ACP | USA | American College of Physicians | Screening, Monitoring, and Treatment of Stage 1 to 3 Chronic Kidney Disease: A Clinical Practice Guideline From the American College of Physicians | 2013 | target patient population for screening is adults, and the target population for treatment it is adults with stage 1 to 3 CKD | clinicians | systematic review | American College of Physicians grading system, adapted from GRADE | ||
HAS | France | Haute Autorité de Santé | Guide de parcours de soins Maladie Rénale Chronique de l’adulte | 2012 | Adult patients with chronic kidney disease. Excluded: patients with end stage renal disease, dialysis or transplantation, inpatients. | General practitioners, dieticians, nurses, pharmacists, etc., and may also concern other health professionals (Nephrologists, cardiologists, diabetologists, physiotherapists, psychologists) | unclear, existing recommendations, expert opinion | no formal grading of evidence or level of recommendation | ||
KDIGO | USA | Kidney Disease Improving Global Outcomes | KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease | 2012 | individuals at risk for or with CKD | Providers: Nephrologists (adult and pediatric), dialysis providers(including nurses), Internists, and pediatricians.patients: Adult and pediatric individuals at risk for or with CKD. Policy Makers: Those in related health fields. | systematic review | GRADE | ||
KHA-CARI | Australia, New Zealand | Kidney Health Australia, Caring for Australasians with Renal Impairment | Early Chronic Kidney Disease | 2013 | patients with kidney disease in Australia & New Zealand, patients with early chronic kidney disease | clinicians and health care workers | systematic review | GRADE | ||
BCMA | Canada | British Columbia Medical Association | Chronic Kidney Disease - Identification, Evaluation and Management of Adult Patients | 2014 | adults aged ≥19 years at risk of or with known chronic kidney disease | The primary audience for BC Guidelines is British Columbia physicians, nurse practitioners, and medical students. However, other audiences such as health educators, health authorities, allied health organizations, pharmacists, and nurses may also find them to be a useful resource | not described | no formal grading of evidence or level of recommendation | ||
UMHS | USA | University of Michigan Health System | Management of Chronic Kidney Disease | 2005 | Interim/minor revision: March, 2014 June, 2016 | adults with chronic kidney disease | clinicians, primary care poviders | systematic review | GRADE, not formally stated | |
VA-DoD | USA | Department of Veterans Affairs, Department of Defense | VA/DoD Clinical Practice Guideline for the Management of Chronic Kidney Disease in Primary Care | 2014 | – | adults 18 years or older with CKD 1–4 without kidney transplant | primary care providers | systematic review | GRADE | |
NICE | UK | National Institute of Health and Care Excellence | Early identification and management of chronic kidney disease in adults in primary and secondary care | 2014 | Update 2015 | Adults 18+ with or at risk of developing chronic kidney disease | Healthcare professionals Commissioners and providers People with chronic kidney disease and their families and carers | systematic review | NICE | |
USPSTF | USA | United States Preventive Services Task Force | Final Recommendation statement, Chronic Kidney Disease: Screening | 2012 | asymptomatic adults without diagnosed CKD | clinicians | probably systematic review “The USPSTF reviewed evidence on screening for CKD, including evidence on screening, accuracy of screening, early treatment, and harms of screening and early treatment.” | one recommendation, not graded |
Quality assessment
CEBAM | HAS | ACP | KDIGO | KHA-CARI | BCMA | NICE | UMHS | VA-DoD | mean | range | ||
---|---|---|---|---|---|---|---|---|---|---|---|---|
Scope and Purpose | 72% | 75% | 81% | 100% | 61% | 58% | 75% | 67% | 89% | 75% | 58% | 100% |
Stakeholder Involvement | 53% | 75% | 8% | 89% | 25% | 31% | 67% | 39% | 61% | 50% | 8% | 89% |
Rigour of Development | 55% | 19% | 53% | 70% | 29% | 17% | 77% | 40% | 59% | 47% | 17% | 77% |
Clarity of Presentation | 72% | 53% | 69% | 100% | 61% | 78% | 81% | 69% | 67% | 72% | 53% | 100% |
Applicability | 50% | 15% | 4% | 29% | 13% | 27% | 60% | 25% | 10% | 26% | 4% | 60% |
Editorial Independence | 96% | 0% | 88% | 79% | 67% | 25% | 88% | 71% | 29% | 60% | 0% | 96% |
weighted mean | 61% | 38% | 42% | 73% | 34% | 36% | 75% | 45% | 54% | 51% | 34% | 75% |
Scope and purpose
Stakeholder and patient involvement
Rigor of development
Clarity of presentation
Applicability
Editorial Independence
Recommendations
Definition
Prevention
CEBAM | USPTF | ACP | HAS | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | |
---|---|---|---|---|---|---|---|---|---|
2012 | 2012 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | |
Prevention and Screening | |||||||||
Prevention | |||||||||
weight management | ▪ | ||||||||
sodium restriction | ▪ | ||||||||
protein restriction | – | ||||||||
smoking abstinence | ▪ | ||||||||
reducing excessive alcohol intake | ▪ | ||||||||
physical exercise | ▪ | ||||||||
Screening | |||||||||
asymptomatic | – | – | – | ||||||
diabetes | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ||
hypertension | ▪ | ▪ | ▪ | ▪ | ▪ | ||||
cardiovascular disease | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ||
acute kidney injury | ▪ | + | ▪ | ||||||
structural renal tract disease, renal calculi, prostate hypertrophia | ▪ | ▪ | |||||||
systemic illness (e.g. SLE, HIV) | ▪ | ▪ | |||||||
positive family history | ▪ | ▪ | ▪ | ▪ | |||||
hematuria | ▪ | ▪ | |||||||
nephrotoxic drugs | ▪ | ▪* | |||||||
smoking | ▪ | ||||||||
age | > 55 | – | |||||||
gender | – | ||||||||
ethnicity | ▪ | ▪ | ▪ | – | |||||
obesity | ▪ | ▪ | – | ||||||
occupational hazards | ▪ | ▪ | |||||||
socioeconomic disadvantage | ▪ |
Screening
Diagnostic tests in newly diagnosed CKD
CEBAM | ACP | HAS | KDIGO | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | |
---|---|---|---|---|---|---|---|---|---|
2012 | 2013 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | |
Diagnostic Tests in newly diagnosed CKD | |||||||||
clinical blood tests | |||||||||
blood pressure | ▪ | ||||||||
serum creatinine | ▪ | ▪ | ▪ | ||||||
(e)GFR (creatinine) | * | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ||
blood count | ▪ | ▪ | |||||||
serum urea | i | ▪ | |||||||
serum uric acid | ▪ | ||||||||
serum albumin | i | ▪ | |||||||
serum electrolytes | ▪ | ▪ | |||||||
serum glucose | ▪ | ▪ | |||||||
lipids | ▪ | ▪ | |||||||
serum cystatin C | i | ||||||||
eGFR (cystatin C) | i | ||||||||
clearance | i | ||||||||
HbA1c | |||||||||
serum calcium | ▪ | i | |||||||
serum phosphate | i | ||||||||
serum phosphorus | i | ||||||||
serum PTH | ▪ | i | |||||||
serum 25-hydroxy-Vitamin D | ▪ | i | |||||||
iron | i | ||||||||
serum electrophoresis | i | i | |||||||
ANA | i | i | |||||||
anti-ENA | i | ||||||||
complement | i | i | |||||||
Hepatitis-B serology | i | ||||||||
Hepatitis-C serology | i | ||||||||
HIV-serology | i | ||||||||
anti-GBM | i | i | |||||||
ANCA | i | i | |||||||
inulin | i | ||||||||
51Cr-EDTA | i | ||||||||
125I-iothalamate | i | ||||||||
iohexol | i | ||||||||
urine tests | |||||||||
albuminuria | ▪ | ▪ | i | ▪ | ▪ | – | |||
proteinuria - reagent strips | - *** | ||||||||
urine albumin-creatinin-ratio (ACR) | ▪** | i | ▪ | n | |||||
urine protein-creatinin ratio (PCR) | ▪** | i | |||||||
urine leucocytes | ▪ | ||||||||
hematuria | ▪ | (▪) **** | unclear***** | ||||||
urine microscopy | ▪ | (−) | |||||||
24 h urine | i | ||||||||
urine electophoresis | i | ||||||||
imaging | |||||||||
renal ultrasound | i | ▪ | ▪ | i | ▪ | i | |||
bladder ultrasound | i | ||||||||
MRI | |||||||||
CT | |||||||||
Angiography | |||||||||
renal artery doppler | i | i | |||||||
invasive | |||||||||
kidney biopsy | i |
Monitoring
CEBAM | ACP | HAS | KDIGO | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | |
---|---|---|---|---|---|---|---|---|---|
2012 | 2013 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | |
Monitoring patients with known CKD | |||||||||
frequency (times /year) | |||||||||
G1/A1 | 1 | 1 | 1 | 1 | ≤1 | ||||
G1/A2 | 1 | 1 | 1 | 1 | 1 | ||||
G1/A3 | 1 | 2 | 2 | 2 | ≥1 | ||||
G2/A1 | 1 | 1 | 1 | 1 | ≤1 | ||||
G2/A2 | 1 | 1 | 1 | 1 | 1 | ||||
G2/A3 | 2 | 2 | 2 | 2 | ≥1 | ||||
G3a/A1 | 2 | 1 | 1 | 1 | 1 | ||||
G3a/A2 | 2 | 2 | 2 | 2 | 1 | ||||
G3a/A3 | 2 | 3 | 3 | 3 | 2 | ||||
G3b/A1 | 2 | 2 | 2 | 2 | ≤2 | ||||
G3b/A2 | 2 | 3 | 3 | 3 | 2 | ||||
G3b/A3 | ≥4 | 3 | 3 | 3 | ≥2 | ||||
G4/A1 | ≥4 | 3 | 3 | 4** | 2 | ||||
G4/A2 | ≥4 | 3 | 3 | 3 | 2 | ||||
G4/A3 | ≥4 | ≥4 | ≥4 | ≥4 | 3 | ||||
G5/A1 | ≥4 | ≥4 | ≥4 | ≥4 | 4 | ||||
G5/A2 | ≥4 | ≥4 | ≥4 | ≥4 | ≥4 | ||||
G5/A3 | ≥4 | ≥4 | ≥4 | ≥4 | ≥4 | ||||
parameter | |||||||||
blood pressure | * | ▪ | ▪ | * | ▪ | * | * | ||
weight | ▪ | ||||||||
(e)GFR | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ||
albuminuria/proteinuria/ACR | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ||
complete blood count | ▪ | ||||||||
iron saturation | ▪ | ||||||||
HbA1c | ▪ | ||||||||
serum calcium | ▪ | ||||||||
serum phosphorus | ▪ | ||||||||
serum potassium | i | i | |||||||
serum albumin | ▪ | ||||||||
complications | ▪ | ||||||||
inulin | i | ||||||||
51Cr-EDTA | i | ||||||||
125I-iothalamate | i | ||||||||
iohexol | i | ||||||||
cardiovascular risk | ▪ | ▪➢ | |||||||
smoking status | ▪ | ||||||||
medication | ▪ | ▪ | |||||||
psychosocial health | ▪ |
Referral criteria
CEBAM | ACP | HAS | KDIGO | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | ||
---|---|---|---|---|---|---|---|---|---|---|
2012 | 2013 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | ||
Referral Criteria | ||||||||||
general | consider individual preferences | ▪ | ▪ | |||||||
consider individual comorbidities | ▪ | ▪ | ||||||||
cooperation or multidisciplinary care | ▪ | i | ▪ | ▪ | ▪ | |||||
routine follow-up after referral by patient’s GP | ▪ | ▪ | ||||||||
nephrologist | GFR < 60 ml/min/1,73m2 | |||||||||
GFR < 45 ml/min/1,73m2 | i | ▪ | ||||||||
GFR < 30 ml/min/1,73m2 | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | |||
ACR > 30 mg/mmol | ▪* | ▪ | ▪ | + hematuria | ||||||
ACR ≥70 mg/mmol | ▪ | i# | ||||||||
proteinuria > 3500 mg/day | ▪ | |||||||||
hematuria | i | ▪* | ||||||||
urinary cell casts | ▪ | |||||||||
constitutional symptoms | ▪ | |||||||||
CKD progression | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | |||
poorly controlled hypertension | ▪ | ▪ | ▪ | ▪ | ||||||
electrolyte disturbance | i | ▪ | ▪ | ▪ | ||||||
anemia | i | ▪ | ▪ | |||||||
metabolic complications | i | ▪ | ||||||||
complications | i | i | ||||||||
nephrolythiasis | ▪ | ▪ | ||||||||
suspected renal artery stenosis | ▪ | ▪ | ||||||||
genetic etiology of CKD | ▪ | ▪ | ▪ | |||||||
rare etiology of CKD | ▪ | |||||||||
etiology requiring specialist care | ▪ | |||||||||
unclear etiology | i | i | ▪ | |||||||
1-year ESRD-risk of ≥10% | ▪ | |||||||||
indication for dialysis or transplant | ▪ | ▪ | ▪ | |||||||
urologist | renal outflow obstruction | ▪ | ▪ | |||||||
diabetologist | diabetic nephropathy | ▪ | ▪ | |||||||
dietician | eGFR< 60 ml/min/1,73m2 | ▪ | i | i | ||||||
inpatient treatment | complications | ▪ | ||||||||
hypertensive crisis | ▪ | |||||||||
unknown etiology | ▪ |
Blood pressure
CEBAM | ACP | HAS | KDIGO | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | ||
---|---|---|---|---|---|---|---|---|---|---|
2012 | 2013 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | ||
Blood pressure management | ||||||||||
BP monitoring intervals | ▪ | |||||||||
individualized BP targets | ▪ | ▪ | ▪ | |||||||
BP target | < 140/90 | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | ▪ | |
BP target in diabetics | < 140/90 | GP | ||||||||
< 140/80 | ||||||||||
< 130/80 | ▪ | ▪ | ||||||||
BP target in ≥ microalbuminuria | < 140/90 | ▪ | ||||||||
< 130/80 | ▪ | ▪ | i | ▪ | ||||||
medication | renin-angiotensin system antagonist | i ➢ | i | |||||||
ACEI | i | i | i | i | i | ▪ | i | |||
ARB | i | i | i | i | ▪ | i | ||||
combination of ACEI + ARB | – | – | – | – | ||||||
combination of ACEI/ARB + direct renin inhibitor | – | – | – | |||||||
diuretics | i | i | ||||||||
β-blocker | i | i | ||||||||
calcium channel blocker | i | i | ||||||||
side effects | ▪ |
Anemia
CEBAM | ACP | HAS | KDIGO | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | ||
---|---|---|---|---|---|---|---|---|---|---|
2012 | 2013 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | ||
Management of anemia | ||||||||||
diagnosis | definition | ▪ | ▪ | ▪ | ▪ | |||||
lower limit in g/dl | 11 | M: 13, F: 12 | M: 13, F: 12 | 11 | ||||||
monitoring | monitor for anemia | ▪ | ▪ | ▪ | i | ▪ | ||||
tests | ▪ | ▪ | ▪ | |||||||
frequency (per year) | individual | 1–4 | ||||||||
initial evaluation | ▪ | |||||||||
treatment options | iron | ▪ | i | ▪ | ||||||
erythropoetin | ▪ | i | ||||||||
nutritional supplements | i | |||||||||
androgens | ||||||||||
blood transfusion | −/i* | |||||||||
treatment | indications | ▪ | ||||||||
target values | ▪ | |||||||||
monitoring | ▪ | |||||||||
erythropoietine resistance | ▪ | |||||||||
referral | ▪ |
Other subjects
other subjects | CEBAM | ACP | HAS | KDIGO | KHA-CARI | BCMA | UMHS | VA-DoD | NICE | |
---|---|---|---|---|---|---|---|---|---|---|
2012 | 2013 | 2013 | 2013 | 2013 | 2014 | 2014 | 2014 | 2015 | ||
patient education | ▪ | ▪ | ▪ | ▪ | ||||||
diet | protein intake (in g/kg/day) | 0.8 | 0.75–1.0 | 0.6–0.8 | ||||||
no low protein diet < 0.6 g/kg/day | ▪ | ▪ | ||||||||
complications | CKD-mineral bone disorder | ▪ | ▪ | ▪ | ▪ | ▪ | ||||
diabetes | HbA1c target values (in %) | 7.0 | < 7.0 | |||||||
metformin | with caution | avoid/reduce | ||||||||
cardiovascular risk | ▪ | |||||||||
hyperlipidemia | ➢ | ➢ | ||||||||
statins for cardiovascular risk | i | i | ||||||||
statins for CKD progression | – | |||||||||
ezetimibe | i | |||||||||
congestive heart failure | ▪ | ▪ | ||||||||
antigoagulants and antiplatelets | ▪ | ▪ | ▪ | ▪ | ||||||
nephrotoxic Medication | geneneral | – | – | |||||||
NSAID | – | |||||||||
vaccinations | ▪ | |||||||||
metabolism | hyperuricemia | ▪ | ▪ | |||||||
oral bicarbonate | ▪ | ▪ | ▪ | |||||||
nephrotoxic medication | ▪ | ▪ | ▪ |
Discussion
Summary of the main results
Quality of guidelines
Content of guidelines
Definition and screening
Diagnostic tests in newly diagnosed CKD
Monitoring
Referral criteria
Blood pressure
Anemia
Other subjects
Strengths and limitations
Directions for future research and guideline development
1 | Recommendations should specify how to consider age, multimorbidity, risk of progression, life expectancy, health goals and quality of life. |
2 | Recommendations on referral should distinguish between interdisciplinary or co-treatment and one-time consultations for specific problems or to rule out specific kidney diseases. |
3 | Guidelines should be comprehensive and include management recommendations for common CKD-related problems usually solved in primary care. |
4 | All relevant options including the option of abstaining from diagnosis or therapy should be incorporated in the guideline. |
5 | Increase involvement of stakeholders and target users, particularly non-nephrologists in the development process. |
6 | Implications for cost and resources in the healthcare system should be considered when formulating recommendations. |
7 | Facilitators and barriers to implementation and adoption of the guideline in clinical practice should be identified and analyzed and the results should be incorporated during the guideline development process. |
8 | A procedure and timeframe for updating the guideline should be specified. |