KDIGO to Become an Independent Entity

It was announced last month that Kidney Disease: Improving Global Outcomes (KDIGO) will make the transition to complete independence beginning October 1, 2012. The news came in a joint statement from KDIGO and its founding sponsor, the National Kidney Foundation (NKF). KDIGO’s co-chair, Bertram Kasiske, MD, said, “the time is right for KDIGO to assume responsibility for its own guideline development processes and management.”

Because of the influence of KDIGO’s recommendations on nephrology practice, could the transition affect the guideline body’s development of future clinical recommendations?

ASN Councilor Sharon Moe, MD, FASN, doesn’t think so. “The transition won’t affect KDIGO in any way other than its internal structure and personnel. It has always been an independent entity with its own board, and has contracted with NKF for management.”

Based in Brussels, Belgium, KDIGO was established in 2003 to improve the care and outcomes of patients with kidney disease by “promoting coordination, collaboration, and integration of initiatives to develop and implement clinical practice guidelines,” according to their mission statement. Before the formation of KDIGO, a few regional kidney practice guidelines were in place. However, the KDIGO model of “international guidelines and local implementation allows an international board to develop these guidelines, and then each country can write a commentary to adapt them for use in their regions,” said Moe, who co-chaired the development of KDIGO’s guideline for chronic kidney disease–mineral and bone disorder (CKD-MBD). “The evidence base from which clinical practice guidelines are generated is international literature,” she said, but the “local country commentary allows for differences in practice, patient populations, and reimbursement structures.”

The KDIGO approach to guideline development is exhaustive, typically lasting 1 to 2 years and involving a work group of as many as 20 experts in the field. The process begins with controversies conferences, where relevant areas of clinical nephrology with existing evidence gaps are identified. Once a guideline candidate is determined, a work group is formed, and the available literature is gathered and evaluated by an independent evidence review team, which Moe emphasized was important to the process. After the evidence has been weighed, the guidelines are drawn, are evaluated by the KDIGO board, and undergo external review before being published and disseminated. Depending on the strength of the evidence available, each practice recommendation is stratified as either level 1 (“patients should receive the recommended course of action”) or level 2 (suggestions for practice, indicating that “different choices will be appropriate for different patients”).

So far KDIGO has published five guidelines for patient care in transplantation, mineral and bone disorders, hepatitis C and CKD, acute kidney injury, and glomerulonephritis. Three additional guidelines—on blood pressure, anemia, and classification of CKD—await publication. In its announcement KDIGO indicated that it would start a new period of guideline development once it becomes a separate entity.

Although focused on clinical care, practice guidelines are also important for clinical research. “One of the goals of guideline development is to identify gaps in knowledge to ensure that future research focuses on these areas,” Moe noted. “It is an interim process: you review the current literature, identify gaps, ensure future research examines those gaps, and then update the guidelines according to the new research—it’s the life cycle of a clinical guideline.”

The KDIGO recommendations have been well respected and implemented throughout the nephrology community. Because of KDIGO’s focus on local implementation, it will continue to partner with NKF to help adapt KDIGO recommendations, through commentaries on regional applicability, to the practice environment in the United States. The NKF will also continue as KDIGO’s educational partner, developing tools and programs to help the dissemination and adoption of KDIGO’s practice recommendations.