KHA-CARI Guidelines: Overview

The Kidney Health Australia - Caring for Australasians with Renal Impairment (KHA-CARI) Guidelines is an evidence-based project that commenced in 1999.

The aim of the KHA-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 clinical practice as often as possible. The guidelines are intended to 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 developed for use in Australia and New Zealand, however, they are used more widely in the region.

KHA-CARI are committed to the development of reliable and trustworthy clinical practice guidelines that follow best practice with respect to guideline development and with a high degree of transparency in all aspects of the process.

Why have guidelines?

Clinical practice guidelines have proved enormously valuable and are now available in most health care 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, 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.

The KHA-CARI Guidelines

The KHA-CARI Guidelines are divided into three disease stages:

  • Chronic Kidney Disease
  • Dialysis
  • Transplantation

More than 100 guideline writers have been involved in researching and writing KHA-CARI guidelines. Guideline writers are invited to attend a one-day methods workshop run by the KHA-CARI office to help equip them for the task of scanning the literature and writing clinical 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.

The KHA-CARI office staff assists writers by conducting systematic literature searches, locating relevant trials and preparing summary evidence tables for each guideline subtopic.

Response from the nephrology community

Surveys of Australian and New Zealand nephrologists and renal nurses were undertaken in 2002 and 2006. Overall, the surveys show that support for the KHA-CARI guidelines is high. In the 2006 survey, results showed that:

  • 91% agree/strongly agree that KHA-CARI provides a useful evidence summary
  • 88% agree/strongly agree the KHA-CARI guidelines cover appropriate areas
  • 60% agree/strongly agree that KHA-CARI has significantly influenced their practice
  • 38% say KHA-CARI has improved health outcomes for renal patients.

In addition to health practitioners, the overall process from a legal viewpoint has also been favourably endorsed. The KHA-CARI guidelines are not intended to replace clinical judgement, but to complement it.

KHA-CARI Guidelines development and updating

The KHA-CARI guidelines are strictly evidence-based and are drawn from the published literature, which is assessed for its level of certainty with respect to both benefits and harms. The intention is to write guidelines based on evidence derived from the optimal studies for the specific question and for which quality and risk of bias have been assessed.

The evidence base for a guideline is evaluated and graded using the approach developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. This is consistent with the approach used by many other international guideline groups and also consistent with requirements of the National Health and Medical Research Council.

The NHMRC recommend that clinical practice guidelines are reviewed every five years, to ensure that guideline contents are kept relatively up to date. Some guideline subtopics may be updated prior to five years, when it is considered there is a need to do so.

Adaptation of guidelines

As they are published, KHA-CARI plans to adapt or write a commentary on the international renal guidelines produced by KDIGO (Kidney Disease: International Guidelines Organisation). This process commenced in 2009 and follows the ADAPTE process. Adaptation of international guidelines should consider the following five key questions:

  • Is there important variation in need (prevalence, baseline risk or health status) that might lead to a different decision?
  • Is there important variation in the availability of resources that might lead to different decisions?
  • Is there important variation in costs that might lead to different decisions?
  • Is there important variation in the presence of factors that could modify the expected effects which might lead to different decisions?
  • Is there important variation in the relative values of the main benefits and downsides that might lead to different decisions?