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    KDIGO Guidelines

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    Brian ER
    This document summarizes 27 guideline statements across 4 major content areas: immunosuppression, graft monitoring and infections, cardiovascular disease risk, and malignancies. It also includes statements on other complications. The initial maintenance immunosuppressive medications section recommends a combination of CNI, antiproliferative agent, and corticosteroids. It suggests tacrolimus as the first-line CNI and mycophenolate as the first-line antiproliferative agent. The long-term maintenance section recommends lowering immunosuppressive medication doses by 2-4 months if no rejection, continuing CNIs rather than withdrawing them, and continuing prednisone if used beyond the first week.

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    KDIGO Guidelines

    Uploaded by

    Brian ER
    64 views41 pages
    This document summarizes 27 guideline statements across 4 major content areas: immunosuppression, graft monitoring and infections, cardiovascular disease risk, and malignancies. It also includes statements on other complications. The initial maintenance immunosuppressive medications section recommends a combination of CNI, antiproliferative agent, and corticosteroids. It suggests tacrolimus as the first-line CNI and mycophenolate as the first-line antiproliferative agent. The long-term maintenance section recommends lowering immunosuppressive medication doses by 2-4 months if no rejection, continuing CNIs rather than withdrawing them, and continuing prednisone if used beyond the first week.

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    This document summarizes 27 guideline statements across 4 major content areas: immunosuppression, graft monitoring and infections, cardiovascular disease risk, and malignancies. It also includes statements on other complications. The initial maintenance immunosuppressive medications section recommends a combination of CNI, antiproliferative agent, and corticosteroids. It suggests tacrolimus as the first-line CNI and mycophenolate as the first-line antiproliferative agent. The long-term maintenance section recommends lowering immunosuppressive medication doses by 2-4 months if no rejection, continuing CNIs rather than withdrawing them, and continuing prednisone if used beyond the first week.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    64 views41 pages

    KDIGO Guidelines

    Uploaded by

    Brian ER
    This document summarizes 27 guideline statements across 4 major content areas: immunosuppression, graft monitoring and infections, cardiovascular disease risk, and malignancies. It also includes statements on other complications. The initial maintenance immunosuppressive medications section recommends a combination of CNI, antiproliferative agent, and corticosteroids. It suggests tacrolimus as the first-line CNI and mycophenolate as the first-line antiproliferative agent. The long-term maintenance section recommends lowering immunosuppressive medication doses by 2-4 months if no rejection, continuing CNIs rather than withdrawing them, and continuing prednisone if used beyond the first week.

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    © All Rights Reserved
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    Download as ppt, pdf, or txt
    of 41

    Guideline Statements

    27 guideline statements
    Major content areas:
    Immunosuppression
    Graft monitoring and infections
    Cardiovascular disease risk
    Malignancies
    Other complications

    Immunosuppression
    1)
    2)
    3)
    4)
    5)
    6)
    7)

    Induction
    Maintenance: initial
    Maintenance: long-term
    Strategies to reduce cost
    Monitoring medications
    Treatment of acute rejection
    Chronic allograft nephropathy

    Graft Monitoring and


    Infections
    8) Monitoring kidney function
    9) Kidney biopsy
    10) Recurrent disease
    11) Non-adnherence
    12) Vaccination
    13) Viral diseases
    14) Other infections

    Cardiovascular Disease Risk

    15) Diabetes mellitus


    16) Hypertension, dyslipidemia, tobacco use and
    obesity
    17) Cardiovascular disease management

    Malignancies
    18) Cancer of the skin and lip
    19) Non-skin malignancies
    20) Immunosuppressive medication reduction

    Other Complications
    21) Bone disease
    22) Hematologic complications
    23) Hyperuricemia and gout
    24) Growth and development
    25) Sexual function and fertility
    26) Life style
    27) Mental health

    Initial Maintenance
    Immunosuppressive Medications
    Recommendations:
    A combination of immunosuppressive medications
    as maintenance therapy including a CNI and an
    antiproliferative agent, with or without
    corticosteroids. (1B)
    Tacrolimus be the first-line CNI used. (2A)
    Tacrolimus or CsA be started before or at the time
    of transplantation, rather than delayed until the
    onset of graft function. (2D tacrolimus; 2B CsA)
    Mycophenolate be the first-line antiproliferative
    agent. (2B)
    CNI, calcineurin inhibitor; CsA, cyclosporine A; mTORi,
    mammalian target of rapamycin inhibitor(s).

    Initial Maintenance
    Immunosuppressive Medications
    (Contd..)

    Recommendations:
    In patients who are at low immunological
    risk and who receive induction therapy,
    corticosteroids could be discontinued
    during the first week after
    transplantation. (2B)
    If mTORi are used, they should not be
    started until graft function is established
    and surgical wounds are healed. (1B)

    Rationale
    Used in combination and at reduced doses, drugs that have
    different mechanisms of action may achieve additive
    efficacy with limited toxicity.
    The earlier that therapeutic blood levels of a CNI can be
    attained, the more effective the CNI will be in preventing
    acute rejection.
    There is no reason to delay the initiation of a CNI, and no
    evidence that delaying the CNI prevents or ameliorates
    DGF.
    Compared to CsA, tacrolimus reduces the risk of acute
    rejection and improves graft survival during the first year
    of transplantation.

    Rationale
    Low-dose tacrolimus minimizes the risk of new-onset diabetes after
    transplantation (NODAT) compared to higher doses of tacrolimus.
    Compared with placebo and azathioprine, mycophenolate reduces
    the risk of acute rejection; there is some evidence
    thatmycophenolate improves long-term graft survival compared
    with azathioprine.
    Avoiding the use of maintenance corticosteroids beyond the first
    week after kidney transplantation reduces adverse effects without
    affecting graft survival.
    Mammalian target of rapamycin inhibitors (mTORi) have not been
    shown to improve patient outcomes when used either as
    replacement for antiproliferative agents or CNIs, or as add-on
    therapy, and they have important short- and long-term adverse
    effects

    Long-Term Maintenance
    Immunosuppressive Medications
    Recommendations:
    Using lowest planned doses of maintenance
    immunosuppressive medications by 2
    4months after transplantation, if there has
    been no acute rejection. (2C)
    CNIs be continued rather than withdrawn. (2B)
    If prednisone is being used beyond the first
    week after transplantation, we suggest
    prednisone be continued rather than
    withdrawn. (2C)

    Rationale
    If low-dose CNI was not implemented at the time of
    transplantation, CNI dose reduction >24months after
    transplantation may reduce toxicity yet prevent acute
    rejection.
    RCTs show that CNI withdrawal leads to increased acute
    rejection, without altering graft survival.
    RCTs show that steroid withdrawal more than 3 months
    after transplantation increases the risk of acute rejection.
    Different immunosuppressive medications have different
    toxicity profiles and patients vary in their susceptibility
    to adverse effects.

    Topic Selection and Prioritization Process

    For Clinical Practice


    Guidelines and
    Conferences

    Prioritization of CPG Development*

    Consistency with the mission of the


    organization.
    Feasibility of implementation.
    Efficiency and utility of the results.

    * Recommendations of the Institute of Medicine

    WHO Guidelines for Guidelines


    Stage 1. Maximum potential benefit to individual
    or group of patients if resources were unlimited.
    Stage 2. Assess tradeoffs between cost of applying
    intervention on a population basis and its health
    impact (very limited vs. unlimited resources).
    Stage 3. Provide evidentiary basis and assistance
    necessary for local Guideline Development Groups
    in adopting and grading the
    recommendations for regional
    implementation considering available
    resources.

    KDIGO Criteria for


    CPG Topic Selection

    Prevalence of clinical problem.


    Burden of illness imposed by the problem.
    Variability in practice
    Potential of guidelines to improve health
    outcomes.

    International Evidence Review Team


    Grading Evidence and
    Recommendations for Clinical
    Practice Guidelines.
    A Position Statement from KDIGO

    Kidney Int 70:2058-2065, 2006

    KDIGO Clinical Practice Guidelines


    Prevention, Diagnosis, Evaluation and
    Treatment of Hepatitis C in Chronic
    Kidney Disease

    Workgroup co-chairs: Michel Jadoul (Belgium) and David


    Roth (USA). Published April 2008, Kidney Int

    Diagnosis, Evaluation, Prevention and


    Treatment of Chronic Kidney Disease
    Related Mineral and Bone Disorders
    (CKD-MBD)

    Workgroup co-chairs: Tilman Dreke (France) and


    Sharon Moe (USA). Anticipated Publication Fall 2008,
    Kidney Int

    Care of the Kidney Transplant Recipient

    Workgroup co-chairs: Bertram Kasiske (USA) and Martin


    Zeier (Germany). Anticipated Publication Winter 2008,
    Kidney Int

    Acute Kidney Injury,

    Workgroup co-chairs: Norbert Lameire (Belgium) and


    John Kellum (USA). Anticipated Publication 2009

    Guideline Coordination Initiative


    Joint effort of leaders of five Englishlanguage guideline development groups
    Exploring the feasibility of a collaborative
    and integrated international approach to
    the development of new guidelines and the
    updating of existing guidelines in the field
    of kidney disease

    Guideline Coordination
    Canadian Society of Nephrology (CSN)
    Guidelines
    Caring for Australians with Renal
    Impairment (CARI) Guidelines - ANZSN
    United Kingdom Renal Association
    Guidelines
    European Best Practice (EBPG) Guidelines
    ERA/EDTA
    Kidney Disease Outcomes Quality Initiative
    (KDOQI) Guidelines - NKF
    KDIGO

    Guideline Coordination
    Globalize (Share) the Evidence Localize
    the Decision Making
    New CPGs: Global KDIGO Guidelines
    Local Implementation
    Existing CPGs: Coordinated, cooperative
    process of updating

    Guideline Coordination
    What we can do together
    Uniformity in grading the evidence and strength of
    recommendations (Grading the evidence and recommendations for
    clinical practice guidelines-A position statement from KDIGO).

    Reconciliation of currently recommended targets (KDIGO


    Website-Compare Guidelines).

    Hepatitis C guidelines as first global guidelines in


    nephrology for subsequent adoption by participating
    organizations, which could then devote their resources to
    implementation. Extend to CKD-MBD and Transplant CPGs,
    with opportunity to provide input and participate early in the
    review process.

    Coordination with WHO


    Liaison member on Guideline
    Development Groups (where
    applicable).
    Participation in Controversies
    Conferences.
    Incorporation of KDIGO CKD Staging
    into ICD 10-11.
    Adopt the WHO Guidelines for
    Guidelines methodology.

    Website Guideline Database


    Comparison of guidelines as a tool
    for the harmonization of
    recommended interventions: The
    KDIGO website

    Kidney International, 2007

    Website Resources
    International Clinical Practice
    Guidelines in Nephrology
    Guideline Development Summaries
    Target Ranges Comparisons
    Position Statements
    CKD-Mineral and Bone Disorder
    Classification of CKD

    www.KDIGO.org

    Website Resources
    Global Nephrology Guideline
    Database:

    Guideline Overviews
    Guideline Summaries by Topic
    Guideline Target Comparisons

    WWW.KDIGO.ORG

    KDIGO Controversies Conferences


    WHAT DO WE KNOW
    (Available Evidence)

    WHAT CAN WE DO WITH WHAT WE


    KNOW
    (Recommendations vs. Guidelines)

    WHAT DO WE NEED TO KNOW

    (Gaps in knowledge, Research questions)

    Third KDIGO
    Controversies Conference

    Care of the Kidney Transplant


    Recipient
    Co-chairs: F. Delmonico, USA
    M. Zeier, Germany
    Lisbon, Portugal
    February 2-4, 2006

    Fourth KDIGO
    Controversies Conference
    CKD as a Global Public Health
    Problem: Approaches and Initiatives
    Co-Chairs: Andrew Levey, Kai-Uwe Eckardt, Adeera
    Levin, Allan Collins, Meguid El-Nahas
    Amsterdam, Netherlands
    October 12-14, 2006

    NKF-KDOQI Definition of CKD


    KDIGO Modifications (Amsterdam 2004)
    Structural or functional abnormalities of the kidneys for >3
    months, as manifested by either:
    1. Kidney damage, with or without decreased GFR, as defined
    by
    pathologic abnormalities
    markers of kidney damage
    urinary abnormalities (proteinuria)
    blood abnormalities (renal tubular syndromes)
    imaging abnormalities
    kidney transplantation

    2. GFR <60 ml/min/1.73 m2, with or without kidney damage

    Conceptual Model for CKD


    Complications
    Complications

    Normal

    Increased
    Increased
    risk

    Screening
    CKD risk
    for CKD
    reduction;
    risk factors:
    Screening for
    diabetes
    CKD
    hypertension
    age >60
    family history
    US ethnic
    minorities

    Damage

    GFR
    GFR

    Kidney
    Kidney
    failure
    failure

    Diagnosis
    Estimate
    Replacement
    & treatment; progression;
    by dialysis
    Treat
    Treat
    & transplant
    comorbid complications;
    conditions;
    Prepare for
    Slow
    replacement
    progression

    CKD
    CKD
    death

    Sixth KDIGO
    Controversies Conference
    Coordination of Global Practice
    Guidelines for Anemia in CKD
    Co-Chairs: Francesco Locatelli &
    Allen Nissenson
    New York
    October 15-16, 2007

    Fifth KDIGO
    Controversies Conference
    Clinical Practice Guidelines:
    Methodology and Transparency
    Co-Chairs: Robert Alpern, Charles
    van Ypersele, Katrin Uhlig, &
    Alison MacLeod
    New York
    October 12-13, 2007

    KDIGO Position Statements


    Definition and classification of chronic kidney
    disease: a position statement from Kidney
    Disease: Improving Global Outcomes (KDIGO)
    Levey AS, at al: Kidney Int 2005;67:2089-2100.
    Definition, evaluation, and classification of renal
    osteodystrophy: a position statement from
    Kidney Disease: Improving Global Outcomes
    (KDIGO) Moe S, et al: Kidney Int 2006;69:1945-1953.
    A report of the Lisbon Conference on the care of
    the kidney transplant recipient. Abbud-Filho M, et
    al: Transplantation 83:S1-22, 2007
    Chronic kidney disease as a global public health
    problem: approaches and initiatives - a position
    statement from Kidney Disease Improving
    Global Outcomes. (KDIGO) Levey AS, et al: Kidney
    Int 72:247-259, 2007

    Mineral and Bone Initiative


    Educational Resources: Clinical Guide to
    Bone and Mineral Metabolism in CKD
    Position Statements: Chronic Kidney
    Disease-Mineral and Bone Disorder
    Bone Biopsy/Bone Biomarker Correlation
    Study

    Clinical Guide to Bone and Mineral


    Metabolism in CKD

    Second KDIGO
    Controversies Conference

    Definition, Evaluation, and


    Classification of Renal
    Osteodystrophy.
    A Position Statement from
    KDIGO
    Kidney Int 69:1945-1953, 2006

    SUMMARY

    Our primary goal is to improve patient care. We hope to


    accomplish this in the short term by helping clinicians know
    and better understand the evidence (or lack of evidence) that
    determines current practice.
    By making this guideline broadly applicable, our purpose is to
    also encourage and enable the establishment and development
    of transplant programs worldwide.
    Finally, by providing comprehensive evidence-based
    recommendations, this guideline will also help define areas
    where evidence is lacking and research is needed.
    Helping to define a research agenda is an often neglected, but
    very important function of clinical practice guideline
    development.
    Kai-Uwe Eckardt, MD
    KDIGO Co-Chair

    Bertram L. Kasiske, MD
    KDIGO Co-Chair

    THANK YOU

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