Background to the CARI Guidelines

The CARI Guidelines is an evidence-based project that commenced in 1999. The two bodies assuming responsibility for the CARI Guidelines are the Council of the Australian and New Zealand Society of Nephrology (ANZSN) and the Board of Kidney Health Australia (KHA).

CARI seeks to improve the quality of care and outcomes for patients with kidney disease in Australia & New Zealand by facilitating the development and implementation of clinical practice guidelines based on the best available evidence and effectiveness.

The CARI guidelines are now divided into three disease stages - Dialysis; Chronic Kidney Disease; and Transplantation. Each guideline comprises various subtopics and their recommendations.

The CARI Guidelines process includes the revision of guidelines every three years to incorporate the latest evidence and keep guidelines relevant. As updating is completed, the finalised guidelines will be published in the journal 'Nephrology'. A number of these publications are planned for 2007/8. Please note that guidelines developed before 2004 were created according to a different process to the current one, and have not been peer reviewed.

The development and review process

Existing guidelines cover the areas of Chronic Kidney Disease; Dialysis and Transplantation. The CARI Guidelines' development and review process has been recently revised to include:

levels of evidence according to the NHMRC classification (6 tiers)
peer review by at least 3 peer reviewers
inclusion of a public consultation phase
the reformatting of existing guidelines with increasing focus on guidelines that are clearly evidence-based (i.e. evidence from randomised controlled trials)
at least 3 face to face meetings for Guideline Group members to assist with meeting deadlines

Implementation

The CARI Office assists writers by locating relevant trials and conducts appropriate literature searches. The Research Officer also develops summary Evidence Tables for each guideline subtopic. Implementation In 2004, the first stage of an Iron implementation project was commenced. This involved performing a clinical audit of 6 renal centres for their practices and procedures regarding Iron levels for their patients and comparison of these results against the CARI guideline on Haemoglobin Targets.

In 2005, the second stage of this project was begun. This stage involves bringing practice in line with the CARI guideline; three of the six renal units that were audited regarding their Iron Management processes are working with the CARI Implementation Team to help bring about agreed practice changes.The CARI process is very demanding of those involved but clearly is an important and worthwhile venture.

The CARI process

The updating and revision of all guidelines is scheduled to occur every 3 years, ensuring that guideline contents are kept relatively up to date. Some guideline subtopics will be updated prior to 3 years, when it is considered there is a need to do so.

Convenors are expected to prompt this process when they become aware of key new evidence that is relevant to their guideline topic. The CARI Guidelines are strictly evidence-based – that is, they are drawn from the published literature, which is carefully assessed for its level of certainty. Only when the conclusions in a particular area are based on a high degree of certainty is the guideline ratified. Recommendations are based on Level I or II evidence according to the NHMRC evidence classification system; Level I refers to “evidence obtained from a systematic review of all relevant randomised controlled trials” and Level II refers to “evidence obtained from at least one properly designed randomised controlled trial.”

Read the CARI Guidelines Annual Report for 2007 to find out about recent guideline development.