The KDIGO Clinical Practice Guidelines for the care of kidney transplant recipients: useful, useless, or simply out of date?
Editor's Note: The KDIGO Clinical Practice Guidelines for the care of kidney transplant recipients was published in a supplement issue of the American Journal of Transplantation(AJT) in 2009 (1).
The full document is available at this link. The rationale, scope, and goals of the guideline are iterated on the KDIGO website at the following link.
Dr. Francis Delmonico from the Department of Surgery, Massachusetts General Hospital, Harvard Medical School writes in Kidney International: “not all of the recommendations may be well received. For example, the recommendation that an interleukin-2 receptor antagonist (IL2-RA) be the first-line induction therapy is highly controversial. The authors give this recommendation a 1B grade, based on ‘moderate quality of evidence,’ indicating that ‘most patients should receive the recommended course of action.’ Further, ‘the recommendation can be adopted as a policy in most situations.’ There are those who would quarrel with this recommendation and whether such a recommendation applies equally to matched living-donor and deceased-donor transplants. The guideline does not distinguish recommendations by the donor source. Much of the kidney transplantation experience in the world occurs through living donation, yet the data applicable to IL2-RA were derived mainly from deceased-donor studies. The cost of an anti-IL2-RA preparation in developing countries that are exclusively using living donors could seemingly be avoided. Finally, the Roche IL2-RA preparation is evidently being suspended, leaving only Novartis's Simulect, which may have limited availability”. Dr. Delmonico also points out that resource constraints particularly in low income countries will make the care of taking care of kidney transplant recipients challenging.
Editor's Note: The KDIGO Clinical Practice Guidelines for the care of kidney transplant recipients was published in a supplement issue of the American Journal of Transplantation(AJT) in 2009 (1).
Dr. Francis Delmonico from the Department of Surgery, Massachusetts General Hospital, Harvard Medical School writes in Kidney International: “not all of the recommendations may be well received. For example, the recommendation that an interleukin-2 receptor antagonist (IL2-RA) be the first-line induction therapy is highly controversial. The authors give this recommendation a 1B grade, based on ‘moderate quality of evidence,’ indicating that ‘most patients should receive the recommended course of action.’ Further, ‘the recommendation can be adopted as a policy in most situations.’ There are those who would quarrel with this recommendation and whether such a recommendation applies equally to matched living-donor and deceased-donor transplants. The guideline does not distinguish recommendations by the donor source. Much of the kidney transplantation experience in the world occurs through living donation, yet the data applicable to IL2-RA were derived mainly from deceased-donor studies. The cost of an anti-IL2-RA preparation in developing countries that are exclusively using living donors could seemingly be avoided. Finally, the Roche IL2-RA preparation is evidently being suspended, leaving only Novartis's Simulect, which may have limited availability”. Dr. Delmonico also points out that resource constraints particularly in low income countries will make the care of taking care of kidney transplant recipients challenging.
We invited Professor Jeremy Chapman to provide a commentary on the impact of the KDIGO Guidelines 2 years after their publication. Professor Chapman is from Westmead Hospital, University of Sydney, Australia and was involved in drafting the KDIGO guidelines. Among several senior roles, Professor Chapman is Past President of the Transplantation Society of Australia and New Zealand.
At a global level Professor Chapman is Immediate President of The Transplantation Society, Past President of the World Marrow Donor Association and Chair of the Global Alliance for Transplantation.
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COMMENTARY
Nearly 1000 references and more than another 11,000 papers read and discarded in the making, the KDIGO guidelines took 2 years work from 5 fulltime academics and an international committee of 15, with the full financial support of the National Kidney Foundation.
Was it worth all those days hidden in some of the worst airport hotels on offer? What has the reaction of the world been? Is it useful, useless, or simply out of date already?
The review covered the care of the patient after a renal transplant, so it doesn’t help in patient or donor selection and it does little for the patient needing to return to dialysis.
The papers that made up the guidelines were almost all published before about mid 2008 and graded for quality (2). My shorthand and simplistic view of that grading is: A = Actually true; B=Believable; C= Could be right; D= Dismal or Dreadful, to which some might add E for ethics papers which can be all or none of the above simultaneously.
The guidelines were produced to help the practicing clinician understand the data available to assist in caring for the kidney transplant recipient: global guidelines unencumbered by any particular national regulatory, fiscal, cultural, socio-economic or geographical environmental.
Sadly lacking in the literature and thus also in the guidelines are any economic analyses to help those in resource constrained environments, so it is written with the rather quaint illusion that money does not dictate treatment choices. Do we advise abandoning a plan to create a transplant program in sub-sarahan Africa simply because the cost of the level 1 (meaning that most people would do this) recommendations on immunosuppression are unaffordable? I don’t think so! Do the KDIGO authors follow every word of the guidelines? No. In fact we carefully disclaim any responsibility for an individual patient or transplant program that follows these guidelines
The Guidelines are fairy accessible, being published in a supplement of AJT, they are also available for free download from many places including The Transplantation Society (TTS) and KDIGO websites (3,4) while the executive summary has been separately published (5). Demonstration of the success of this strategy came from the fact that the guidelines were downloaded more than 6,000 times in the first 24 hours from the TTS website alone. 9 reviews or commentaries on the guidelines have been published (though two of those were authored by me and perhaps don’t count) and specialists in the USA, Europe, Australia and Canada have reviewed and in some cases updated the guidelines to suit their own environments.
What has failed to stand the test of even three years?
The most recent review challenges a number of areas of the guidelines either because new data have come to light, or simply there is a disagreement with the original grading team. Immunosuppression induction; long term maintenance therapy and treatment for rejection, all get a swipe by the recent European reviewers.
There is also an unbecoming reticence to advise clinicians to actually discover the underlying histology of the deteriorating graft. It is rather unkind, but perhaps not entirely unfair, to label guidance on recurrent glomerulonephritis as little better than “suggestions guided by educated guesses”.
However the updating of guidance on the impact of the viruses BKV, EBV and CMV seems to be warranted by the new data available since 2008. Lipid lowering guidelines get the last comment for being too specific with unproven benefits.
Do the guidelines have a practical value?
At one level they provide reassurance to the clinician and patient that data underpins decisions in the care of the renal transplant recipient.
But sadly, the thin veneer of reliable data is exposed by the fact that a little over 2/3rds of the advice provided to the guidelines reader has only level C or D (C= Could be right; D= Dismal) strengths of evidence showing how soon our science runs out of steam.
It hasn’t stopped the KDIGO guidelines being useful, and while some areas are dating a little, it will be a few years yet before a full revision is mandated.
References
1. Kasiske BL, Zeier MG, Chapman JR, Craig JC, Ekberg H et al. KDIGO Clinical Practice Guideline for the care of kidney transplant recipients. AJT 2009; 9 (S3) 1- 155.
2. Uhlig K, Macleod A, Craig JC et al. Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 70: 2058-2065
3. http://tts.org/kdigo/downloads/kdigo/KDIGO_KidneyTxGuideline.pdf
4. http://www.kdigo.org/clinical_practice_guidelines/pdf/TxpGL_publVersion.pdf.
5. KDIGO clinical practice guideline for the care of kidney transplant recipients: a summary. Kasiske BL, Zeier MG, Chapman JR, Craig JC, Ekberg H, et al. Kidney Int. 2009 Oct 21.
6. Endorsement of the Kidney Disease Improving Global Outcomes (KDIGO)guidelines on kidney transplantation: a European Renal Best Practice (ERBP) position statement. Heemann U, Abramowicz D, Spasovski G, Vanholder R; European Renal Best Practice Work Group on Kidney Transplantation. Nephrol Dial Transplant. 2011 Jul;26(7):2099-106
