- How should this guideline be used?
Clinical Practice Guidelines are documents that present evidence-based recommendations to aid clinicians in the treatment of particular diseases or groups of patients. They are not intended to be mandates but tools to help physicians, patients, and caregivers make treatment decisions that are right for the individual. With all guidelines, clinicians should be aware that circumstances may appear that require straying from the published recommendations.
This Update is intended to be referenced in combination with the KDOQI Clinical Practice Guideline for Hemodialysis: Update 2006.
- How have recommendations changed since the 2006 Hemodialysis Adequacy update?
There are not significant differences between the 2006 version and this update because much of the newer evidence supports older study results. However, this update puts more emphasis on shared, patient-physician decision making and less emphasis on rigid minimum or maximum thresholds. There are also recommendations regarding high frequency hemodialysis in this update, including risks for certain patient populations, and the use of stdKt/V to measure frequent hemodialysis. This update puts more emphasis on controlling volume and blood pressure. Previous recommendations on topics that have not been addressed in this update (ie. methods for postdialysis blood sampling, pediatric hemodialysis prescription, and quality improvement programs) are still relevant.
- Who wrote the Hemodialysis Adequacy Update 2015?
The National Kidney Foundation convened a workgroup of nephrologists, selected for their clinical expertise as well as experience with clinical trials and familiarity with the literature relating to dialysis adequacy. These clinicians volunteered their time over two years, working with NKF to commission a literature review and draft the resulting clinical practice recommendations. They are: John Daugirdas MD, Thomas A. Depner MD, Jula Inrig MD, Rajnish Mehrotra MD, Michael V. Rocco MD, Rita Suri MD, and Daniel E. Weiner MD. The literature review was carried out by the Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research at the University of Minnesota.
- Why are some statements 'ungraded'?
The authors have given each recommendation two grades: a number representing the strength of the recommendation—how strongly they feel about it in consensus—either 1 ("we recommend") or 2 ("we suggest"); and a letter representing the quality of evidence available to make the recommendation (A-D, A is highest quality evidence). In some cases, there were topics on which the authors felt patients and clinicians would seek guidance, but there was not yet enough published research to make a recommendation based on evidence alone. In these cases the authors have made recommendations based on expertise, experience, and lower quality evidence. Such recommendations are marked as 'ungraded'.
- Why doesn't the guideline give a recommended ultrafiltration rate limit, blood pressure target, or more specific thresholds?
For some questions, the workgroup did not find sufficient strength of evidence to recommend a range or absolute limit for all patients. In these cases, they address the options in the recommendation and present the available evidence in the subsequent rationale. More broadly, this clinical practice guideline highlights the need for individual prescription flexibility, essentially more patient-centered care, in hemodialysis.
- Why isn't there more emphasis on short, home hemodialysis and related technology?
While observational studies on home hemodialysis are beginning to show promising improvements in reported quality of life and clinical outcomes, this literature review was based on clinical trials. The evidence review team and workgroup did not analyze evidence concerning frequent home dialysis modalities with lower dialysate flow rates, given the paucity of studies on these newer technologies at the time of review. Therefore the recommendations provided cannot be extrapolated to these devices. That said, the topic of home hemodialysis deserves further research, and with its increasing popularity, practitioners deserve guidance. This is something we will look into with future KDOQI guideline and resource development.