The KDIGO Practice Guideline on Glomerulonephritis

Reading Between the (Guide)Lines-Application to the Individual Patient

Jai Radhakrishnan; Daniel C Cattran

Disclosures

Kidney Int. 2012;82(8):840-856. 

In This Article

Abstract and Introduction

Abstract

The KDIGO guideline for glomerulonephritis is designed to assist health-care providers in treating patients with glomerular diseases. A guideline is not a set of rules but is intended to allow the practitioner to make an informed decision based on the available evidence. Due to its general nature and the variability of strength of the available studies, it is often difficult to directly apply a guideline to the care of an individual patient. This commonly relates to the limited generalizability of the evidence, i.e., does not cover every clinical scenario. To underscore this point, we have introduced within the context of the glomerulonephritis guideline cases with specific features to illustrate the constant need for clinical judgment. These vignettes are intended to demonstrate how the best treatment plans should be individualized and take into account patient preference and clinical acumen, as well as the best available evidence.

Introduction

Clinical practice guidelines (CPGs) have become a mainstay in clinical practice and have encompassed every single branch of medicine. As defined by the Institute of Medicine, clinical guidelines are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'.[1] The potential benefits of CPGs are many. By providing clear recommendation based on current evidence, CPGs can improve the quality of clinical decisions. Evidence-based guidelines support interventions that are of proven benefit while documenting the quality of the supporting data. Further, interventions unsupported by good science are also reviewed and call attention to ineffective (or even dangerous) practices. On the flip side, there is also the possibility that CPGs could have negative consequences.[2] In the situation in which only a few studies are of high enough quality, many recommendations made by guideline committees are subjective and 'opinion-based'. Further, despite good-quality data, a recommendation may not be suitable for a particular patient. Finally, applications of nonmedical values combined with intense pressures on health-care provision can create an environment for guideline misuse.[3]

Although CPGs have been shown to improve the quality of care,[4] whether they achieve this in daily practice is less clear.[2] In an analysis of 59 CPG evaluations covering a wide range of clinical activities, all but 4 detected statistically significant improvements in the process of medical care. Moreover, all except 2 of the 11 evaluations that also measured the outcome of care reported significant improvements in outcome.[4] Guidelines that are likely to change medical practice have a few characteristics in common. First, they are likely to be developed internally by the very physicians who are going to use them. Second, appropriate development, dissemination, and implementation strategies are adopted during their introduction. Last, implementation strategies that are operative within the doctor–patient consultation are more likely to be effective.[5]

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