CARI - Caring for Australasians with Renal Impairment

The CARI Guidelines is an evidence-based project that commenced in 1999. The two bodies assuming responsibility for the CARI Guidelines are the Council of the Australian and New Zealand Society of Nephrology (ANZSN) and the Board of Kidney Health Australia (KHA).

The aim of the CARI Guidelines is to improve the health care and outcomes of paediatric and adult patients with kidney disease by helping clinicians and health care workers to adhere to evidence-based medical practice as often as possible. It is anticipated that the guidelines will serve as both a valuable educational resource and a means of enhancing the quality, appropriateness, consistency and cost-effectiveness of renal health care. The guidelines were initially developed for use in Australia but we are now keen for them to become regional guidelines.

Publications

By the end of 2005, a total of 17 major Practice Guidelines had been researched and written, with 3 Supplements published in the journal Nephrology.

In December 2005, the guidelines on Nutrition and Growth in Kidney Disease and one on Lipid-lowering therapy were published. A total of 22 subtopics were covered.

In October 2005, a Supplement with revised guidelines on Acceptance onto Dialysis; Dialysis Adequacy; Haemoglobin; Deceased Kidney Donor Suitability; and Evaluation of Renal Function (new guidelines) was published. A total of 25 individual subtopics were researched and written.

In October 2004, a Supplement containing new guidelines on Urine Protein; CMV Disease; and Peritonitis Treatment and Prophylaxis was produced. In all, 21 subtopics were written about.

More recently, in April 2006, a Nephrology Supplement containing revised guidelines on Prevention of Progression of Kidney Disease; Biochemical & Haematological Targets; and Management of Bone Disease, Calcium, Phosphate and PTH was published. Overall, 50 individual subtopics were covered in this publication.

The new guideline topic currently being worked on is 'Renal Vasculitis'. Draft recommendations will be presented for discussion at the Dialysis, Nephrology and Transplantation (DNT) Workshop to be held in Queenstown, New Zealand in March 2007. About 100 guideline writers have been involved in researching and writing guidelines so far. Guideline writers are invited to attend a one-day Methods Workshop run by the CARI Office to help equip them for the task of scanning the literature and writing their Practice Guidelines. This training teaches participants how to critically review and summarise the relevant literature on their topic, how to grade the quality of studies and integrate them into their guidelines, and in general, improves their critical appraisal skills.

Existing guidelines cover the areas of Chronic Kidney Disease; Dialysis and Transplantation. The CARI Guidelines' development and review process has been recently revised to include:

levels of evidence according to the NHMRC classification (6 tiers)
peer review by at least 3 peer reviewers
inclusion of a public consultation phase
the reformatting of existing guidelines with increasing focus on guidelines that are clearly evidence-based (i.e. evidence from randomised controlled trials)
" at least 3 face to face meetings for Guideline Group members to assist with meeting deadlines.

The CARI Office assists writers by locating relevant trials and conducts appropriate literature searches. The Research Officer also develops summary Evidence Tables for each guideline subtopic.

Implementation

In 2004, the first stage of an Iron implementation project was commenced. This involved performing a clinical audit of 6 renal centres for their practices and procedures regarding Iron levels for their patients and comparison of these results against the CARI guideline on Haemoglobin Targets. In 2005, the second stage of this project was begun. This stage involves bringing practice in line with the CARI guideline; three of the six renal units that were audited regarding their Iron Management processes are working with the CARI Implementation Team to help bring about agreed practice changes.

CARI obtained a seeding grant in 2005 from the National Institute of Clinical Studies (NICS) which enabled a consultation process to be held with representatives of all sectors of the organ donation process. As a result, the organ donation process was mapped and barriers to increasing donation rates were documented. The next stage will involve the implementation of this project over a 2-year period.

Research activity

Research on implementation strategies that can be used in chronic kidney disease is being carried out by Michelle Irving, the CARI Research Officer responsible for implementation. This is in the form of a systematic review. A survey has also been sent to registered nephrologists in Australia and New Zealand and to renal nurses in Australia, asking for their opinion of the CARI Guidelines thus far and for their input to help shape the future direction of the project.

Qualitative research into the research priorities for the patient, parent and healthcare provider is being undertaken by Allison Tong, the CARI Research Officer. The experiences and perspectives of the three groups is being sought to improve the healthcare given to patients and to identify what the research priorities are for each group. The first of a series of focus groups was recently held. Four renal centres are involved in this project.

Response from the nephrology community

A survey of the Australasian nephrology community shows that support for the CARI Guidelines among medical and nursing staff is high and the overall process from a legal viewpoint has also been favourably endorsed. The CARI Guidelines are not intended to replace clinical judgement, but rather to complement it.

The CARI process

The CARI process is very demanding of those involved but clearly is an important and worthwhile venture. The updating and revision of all guidelines is scheduled to occur every 3 years, ensuring that guideline contents are kept relatively up to date. Some guideline subtopics will be updated prior to 3 years, when it is considered there is a need to do so. Convenors are expected to prompt this process when they become aware of key new evidence that is relevant to their guideline topic.

The CARI Guidelines are strictly evidence-based - that is, they are drawn from the published literature, which is carefully assessed for its level of certainty. Only when the conclusions in a particular area are based on a high degree of certainty is the guideline ratified. Recommendations are based on Level I or II evidence according to the NHMRC evidence classification system; Level I refers to "evidence obtained from a systematic review of all relevant randomised controlled trials" and Level II refers to "evidence obtained from at least one properly designed randomised controlled trial."

Why have guidelines?

Clinical practice guidelines have proved enormously valuable and are now available in most specialties. It is believed that adherence to the recommendations translates directly into benefits for patients through improved outcomes, benefits for practitioners through improved quality of care, and benefits for providers through improved cost effectiveness. Guidelines are considered to reduce the use of unnecessary, ineffective or harmful interventions, and to facilitate the treatment of patients with maximum chance of benefit, with minimum risk of harm, and at an acceptable cost. Research has shown that clinical practice guidelines can be effective in bringing about change and improving health outcomes.

Acknowledgement

The CARI Guidelines have been developed through the voluntary effort of many participating physicians. Support for the resources needed to allow this process to proceed to completion has come largely from unrestricted development grants from Amgen Australia and Janssen-Cilag Pty Ltd.

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