• 1.

    Nesrallah GE, et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ 2014; 186:112117.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int Suppl 2012; 2:139274.

    • Search Google Scholar
    • Export Citation
  • 3.

    ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: Main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation 2011; 124:12501259.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012; 2: 1138.

    • Search Google Scholar
    • Export Citation
  • 5.

    Ketteler M, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: What’s changed and why it matters. Kidney Int 2017; 92:2636.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Hiremath S, Akbari A. Calcium-based phosphate binders and chronic kidney disease. Lancet 2014; 383:216.

  • 7.

    Ruzicka M, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for the management of blood pressure in CKD. Am J Kidney Dis 2014; 63:869887.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Husten L. Why health guidelines should be waged like war. Forbes Magazine August 2014. https://www.forbes.com/sites/larryhusten/2014/08/22/why-guidelines-should-be-waged-like-war/. Accessed November 18, 2019.

    • Search Google Scholar
    • Export Citation
  • 9.

    Nerenberg KA, et al. Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018; 34:506525.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Williams B, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:30213104.

  • 11.

    Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA /PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018; 71:e13e115.

    • Search Google Scholar
    • Export Citation
  • 12.

    Qaseem A, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017; 166:430437.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int Suppl 2012; 2: 337414.

    • Search Google Scholar
    • Export Citation
  • 14.

    Gabb GM, et al. Guideline for the diagnosis and management of hypertension in adults - 2016. Med J Aust 2016; 205:85-89.

KDIGO: One Guideline to Rule Them All?

  • 1 Swapnil Hiremath, MD, MPH, FASN, is Staff Nephrologist at the Ottawa Hospital, an Associate Professor at the University of Ottawa, and an Associate Scientist at the Ottawa Hospital Research Institute, Ottawa, Canada.
Full access

“Rules are for the guidance of wise men and the obedience of fools.” Group Captain Sir Douglas Bader, 1910–1982

One of the first major guidelines in nephrology was the Dialysis Outcomes Quality Initiatives (DOQI), which later morphed into the KDOQI guidelines that we all know today. Good as they were, they were developed by the National Kidney Foundation, based in the United States, and other countries went their own way. The Canadian Society of Nephrology has had slightly different variations in their guidelines, its last major one from 2011, on the timing of initiation of dialysis (1). One reason for this lull is that producing guidelines is a time-intensive and resource-intensive process. So, 15 years ago, when Kidney Disease: Improving Global Outcomes (KDIGO) came into being, there was a collective sigh of relief. The KDIGO Work Groups include experts from all over the world; they undergo a rigorous process and use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for appraising the evidence and making the recommendations.

So how have the past 11 years of living in the KDIGO era been since its first guideline? It has been a mixed bag, to be sure. Paradoxically, one of the most useful guidelines, which this author has personally referred to the most, has been the one for which the evidence is the thinnest. The glomerulonephritis guideline covers each glomerular disease separately, and the best way to think of them is as excellent review articles covering the existing evidence and giving helpful advice (2).

Some other guidelines veer off strangely in places—perhaps related to the process and timelines. In 2011, the largest trial of N-acetylcysteine in contrast–induced acute kidney injury with a sample size five times larger than in any previous study, was published (3). Despite the clear results of this trial showing no benefits, the 2012 KDIGO acute kidney injury guideline recommended the use of N-acetylcysteine (Grade 2D) (4). There was also a Grade 2B recommendation for the use of citrate over heparin in continuous renal replacement therapy. Given the logistics and cost implications of citrate continuous renal replacement therapy, this does read like ivory tower academia interpreting the evidence narrowly and calling the shots. Similarly, even in the revised mineral bone disease guideline (MBD), a 2017 update calls for routine bone mineral density testing (5). What does one do with those data, given that there is not a single trial with clinically relevant outcomes to guide therapy in this area? The Grade 2B recommendation to avoid or limit the use of calcium-based phosphate binders relies on data that are not very robust, to say the least (6).

But these are minor quibbles. There has been much progress overall; for example, the 2017 update took away some of the egregiously narrow MBD targets and sensibly allows for analysis of trends before decisions are made. The “research needs” paragraphs at the end of each section have been helpful for researchers to focus their efforts on high-yield topics. From a local perspective, the KDIGO guidelines serve as a baseline starting point, and the Canadian Society of Nephrology is then able to publish their review of the KDIGO guidelines, adding their perspective, points to highlight, and recommendations on which the Canadian guidelines differ, with a detailed supporting rationale (7).

What should come next for KDIGO? There is now a greater focus on patient-reported outcome measures and patient-reported experience measures, and some incorporation of these elements is a natural progression. There is also a greater shift away from experts who may have conflicts of interest in the wider guideline world—and this is decidedly a complex topic but worthy of consideration. Last, do we need more guidelines or fewer guidelines? As has been famously said, perhaps guidelines should be like wars, waged only when there is absolute consensus and overwhelming evidence (8). In the case of nephrology, sadly, we might end with very few guidelines if we follow this advice. Another way of looking at the problem is to view them truly like guidelines—for guidance, not as quality metrics or performance measures. The aforementioned glomerulonephritis guideline represent an obvious example of how this can play out.

Paradoxically, one area in which this clinician is eagerly waiting for the KDIGO guidelines to drop is a guideline for hypertension, for which there is no lack of existing guidelines. The current buffet of blood pressure (BP) guidelines leaves much to be desired and serves to confound and confuse the unwary clinician. Table 1 shows the smorgasbord of available advice on BP management (914). The choices range from the 130/80 mm Hg one size fits all to the systolic BP <120 mm Hg because CKD means high cardiovascular risk, but not if you are diabetic, in which case it’s <130/80 mm Hg, but if GFR is <20 then maybe it should be <140/90 mm Hg. The recently released European guidelines also have a floor, with a BP target being <140 mm Hg but not less than 120 mm Hg. In this bewildering Byzantine area, KDIGO can serve as a beacon of clarity. Let’s hope the BP Work Group lives up to our hopes and expectations.

Table 1.

Summary of existing national and international hypertension guidelines, as of June 2019

Table 1.
AAFP, American Academy of Family Physicians; ACC, American College of Cardiology; ACP, American College of Physicians; AHA, American Heart Association; CKD, chronic kidney disease; CV, cardiovascular; DBP, diastolic blood pressure; DM, diabetes mellitus; ESC, European Society of Cardiology; ESH, European Society of Hypertension h/o, history of; HTN Canada, Hypertension Canada; KDIGO, Kidney Disease: Improving Global Outcomes; NHF, National Heart Foundation of Australia; SBP, systolic blood pressure.

References

  • 1.

    Nesrallah GE, et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ 2014; 186:112117.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Kidney Disease: Improving Global Outcomes (KDIGO) Glomerulonephritis Work Group. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int Suppl 2012; 2:139274.

    • Search Google Scholar
    • Export Citation
  • 3.

    ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: Main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation 2011; 124:12501259.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012; 2: 1138.

    • Search Google Scholar
    • Export Citation
  • 5.

    Ketteler M, et al. Executive summary of the 2017 KDIGO Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) Guideline Update: What’s changed and why it matters. Kidney Int 2017; 92:2636.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Hiremath S, Akbari A. Calcium-based phosphate binders and chronic kidney disease. Lancet 2014; 383:216.

  • 7.

    Ruzicka M, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO clinical practice guideline for the management of blood pressure in CKD. Am J Kidney Dis 2014; 63:869887.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Husten L. Why health guidelines should be waged like war. Forbes Magazine August 2014. https://www.forbes.com/sites/larryhusten/2014/08/22/why-guidelines-should-be-waged-like-war/. Accessed November 18, 2019.

    • Search Google Scholar
    • Export Citation
  • 9.

    Nerenberg KA, et al. Hypertension Canada’s 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018; 34:506525.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Williams B, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:30213104.

  • 11.

    Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA /PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018; 71:e13e115.

    • Search Google Scholar
    • Export Citation
  • 12.

    Qaseem A, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med 2017; 166:430437.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13.

    Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int Suppl 2012; 2: 337414.

    • Search Google Scholar
    • Export Citation
  • 14.

    Gabb GM, et al. Guideline for the diagnosis and management of hypertension in adults - 2016. Med J Aust 2016; 205:85-89.

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