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KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations – 2006 Updates
by ANNA President JoAnne Gilmore
The
2006 Hemodialysis (HD) Adequacy, Peritoneal Dialysis (PD) Adequacy, and
Vascular Access KDOQI updates were published recently (NKF, 2006).
These new documents have been divided into three major areas, which are
discussed below.
Overview of Sections
The
first section consists of guideline statements that are evidence based.
The second section is a new section that consists of opinion-based
statements that are called “clinical practice recommendations.” The
clinical practice recommendations are opinion based and are based on
the expert consensus of the Work Group members. The intention of the
Work Group members was that the guideline statements in Section 1 be
considered for clinical performance measures because they are supported
through evidence-based practice. Because the clinical practice
recommendations are opinion based, they should not be considered to
have sufficient evidence to support the development of clinical
performance measures.
The third section consists of research recommendations for these
guidelines and clinical practice recommendations. The Work Group
members decided to combine all research recommendations for the
guidelines into one major section and have ranked these recommendations
into three categories: (a) critical importance, (b) high importance,
and (c) moderate importance. The Work Group members presented these
research recommendations to provide a guidepost for funding agencies
and investigators to target research efforts in areas that will provide
important information to benefit patient outcomes. As we all know,
implementation is a critical component of the KDOQI process. With that
in mind, the National Kidney Foundation’s Kidney Learning System (KLS)
is developing implementation tools for these guidelines.
Guideline 1:
Initiation of Dialysis. Guideline 1 is titled “Initiation of Dialysis”
and states that patients who reach CKD Stage 4 (estimated GFR less than
30 mL/min/1.73 m2) should receive timely education about kidney failure
and options for its treatment, including kidney transplantation, PD, HD
in the home or in-center, and conservative treatment. Patients’ family
members and caregivers also should be educated about treatment choices
for kidney failure. As I read this guideline, I think of living in an
ideal world where our patients and their families could receive
education prior to reaching stage 4. Am I dreaming? Maybe, probably,
but isn’t it nice to dream?
The rationale for early education should ring a bell for all nephrology
nurses, and certainly our APNs and CKD nurses. It states that timely
education will:
- allow patients and families time to assimilate the information and weigh treatment options,
- allow evaluation of recipients and donors for preemptive kidney transplantation,
- allow staff time to train patients who choose home dialysis,
- ensure that uremic cognitive impairment does not cloud decisions, and
- maximize the probability of orderly and planned treatment initiation using a permanent access.
Guideline 2:
PD Adequacy. The PD Adequacy guidelines represent a complete revision
of the original guidelines. The guidelines are primarily for patients
on continuous ambulatory PD (CAPD) and are organized into clinical
practice guidelines and clinical practice recommendations. The
guidelines are based on available evidence if it exists. Per the
authors, much more evidence is needed; therefore they are strongly
discouraging oversight bodies from using the clinical practice
guidelines for clinical performance measurements. Of note, in the
original PD guidelines, a target goal for solute clearance was
recommended. In the updated guidelines, a minimum dose is recommended.
But again, education beginning in CKD Stage 4 is emphasized.
Guideline 3:
Vascular Access. And finally, the Achilles Heel for many of our
patients, vascular access. The guidelines stress the goal of early
identification of patients with progressive kidney disease and the
identification and protection of potential fistula construction sites –
particularly sites using the cephalic vein – by members of the health
care team and patients. There are explicit guidelines regarding which
tests to use to evaluate a given access type and when and how to
intervene to reduce thrombosis and underdialysis. The Work Group
believes these guidelines are reasonable, appropriate, and achievable
and that attainment of the goals will require the concerted efforts of
patients and the entire health care team.
Summary
In scanning through the KDOQI guidelines for this article, I applaud
the Work Group members as there is an emphasis placed on timely
education of the patient, their family members, close friends, and/or
primary care providers for both HD and PD. We have all seen in our
practice setting, how critical education is for our patients. Studies
have shown that timely patient education as CKD advances can both
improve outcomes and reduce cost. These guidelines certainly emphasize
the importance of advocating for education of patients with CKD. We
know that we as nephrology nurses are crucial for educating the patient
with CKD, the patient with ESRD, family members, and caregivers and for
re-enforcing their education.
JoAnne Gilmore, BSN, RN, CNN
ANNA President
References
National
Kidney Foundation (NKF). (2006). KDOQI clinical practice guidelines and
clinical practice recommendations for 2006. Updates: Hemodialysis
adequacy, peritoneal dialysis adequacy and vascular access. American
Journal of Kidney Disease, 48(Suppl 1), S1-S322.
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