Chronic kidney disease in adults—UK guidelines for identification, management and referral
Edited by the Royal College of Physicians and the Renal Association – March 2006
Renal Division, University Hospital Ghent, Belgium
In March 2006, UK guidelines on how to approach the problem of chronic kidney disease, essentially in non-dialysed patients, were published thanks to a collaborative effort of the Royal College of Physicians, the Royal College of General Practitioners and the Renal Association. These comprehensive guidelines cover the broad scale of problems that might occur in subjects with chronic kidney disease not yet on dialysis. The text is well-written and covers many aspects of therapeutic issues relating to this long-neglected and emerging problem. Many of the statements may be more useful to non-nephrologists than to nephrologists per se. There arises a problem of implementation, of which the authors are well aware and which is discussed in the ‘Introduction’, but one cannot deny the impression that there are not many practical means and funds available to achieve what the authors would perceive as an ideal implementation record.
Although called guidelines in the general title, the booklet itself mentions only recommendations, which refer semantically to a lower strength and authority than proper guidelines. From the text, it becomes clear that many of the issues dealt with have not been submitted to randomized controlled trials (RCTs); thus, the use of the term recommendations is more acceptable, but then this word should also have been used in the general title.
In this era of global guidelines, one might wonder whether there is still room for national guidelines, especially since there are also European Best Practice Guidelines (EBPG). UK can be assumed to be a part of Europe. The authors also try to position their text within this context of emerging globalization. They stress that the driving force for their initiative was that each country has its own specific conditions that warrant separate guidelines. More likely, the initiative for the guidelines discussed here was probably taken before it became known that worldwide initiatives, such as the Kidney Disease: Improving Global Outcomes (KDIGO), had been established to deal globally with the nephrological guideline issue.
In addition, the process of developing global guidelines will be a gradual one, and not all issues will be covered at the same time, leaving some space for local guidelines until such time as the global initiative is working at full strength.
Undeniably, what is stated in these ‘guidelines’ is impressively perfect, but gives a kind of ‘déja vu’ impression, if one considers that the Caring for Australians with Renal Impairment (CARI), Kidney Disease Outcomes Quality Improvement (K/DOQI), Canadian Nephrological Society (CNS) guidelines and European Best Practice Guidelines (EBPG), have all dealt with many if not all of the aspects discussed in this issue.
There is no effort in these guidelines to present evidence levels or quality assessment of the publications used and referred to. There was no neutral instance performing literature searches; the authors apparently performed their searches themselves. There are no details on the peer review process once the guidelines were developed, nor how adaptations were made accordingly.
Sometimes quite bald positions are taken, and the necessary nuances are mentioned only in the rationale, which does not immediately follow the recommendation, but is included in a separate part of the text. This reviewer is afraid that as a consequence, the recommendations will be read, but not the rationale. A striking example of this is the recommendation to calculate glomerular filtration rates (GFRs) out of serum creatinine by the modification of renal disease by diet (MDRD) formula. That serum creatinine measurements may differ from laboratory to laboratory, inducing a potential danger of misclassification of chronic kidney disease, is stressed in the ‘Supporting Evidence’ discussion, but if one reads the recommendations alone this nuance is lost.
Some recommendations are followed by references between brackets such as (1), (2), and (3DA). There should certainly be good reasons for this, and somewhere in the text there might be an explanation, but it is not very easy to find, at least not for this reviewer.
All in all, these are useful guidelines; however, to a large extent they repeat previous efforts.
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