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The aim of the KHA-CARI Guidelines 
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 medical practice as often as possible. It is anticipated that the guidelines will 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 initially developed for use in Australia, however they are now being used more widely in the region.

Why have guidelines?
Clinical practice guidelines have proved enormously valuable and are now available in most 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, with 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.

Development and review process
Existing guidelines cover the areas of Chronic Kidney Disease; Dialysis and Transplantation. Each guideline comprises various subtopics and their recommendations. The KHA-CARI Guidelines' development and review process has been recently revised to include:

• evidence rating according to the GRADE system
• peer review by at least 3 peer reviewers
• inclusion of a public consultation phase
• reformatting of existing guidelines with increasing focus on guidelines that are clearly evidence-based
• at least 3 face to face meetings for Guideline Group members to assist with meeting deadlines  

The CARI process
The CARI process is very demanding of those involved but clearly is an important and worthwhile venture. 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 KHA-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. The intention is to write guidelines based on evidence derived from the optimal studies for the specific question.

In July 2009, it was decided that the evidence base should be evaluated and graded using the approach developed by the GRADE Working Group (www.gradeworkinggroup.org). This is consistent with the approach used by many other guideline groups.

CARI continues to use a tiered approach with a clear distinction between 'Guideline Recommendations' and 'Suggestions for Clinical Care'. A Guideline Recommendation requires evidence to be obtained from optimal studies, while a Suggestion for Clinical Care can be written based on evidence obtained from sub-optimal studies, subject to an assessment of the quality of the evidence. The NHMRC levels of evidence table is used to identify optimal and sub-optimal studies.

Adaptation of guidelines
CARI plans to adapt the international renal guidelines produced by Kidney Disease: International Guidelines Organisation (KDIGO) as they are produced from 2009 onwards, based on 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?

Dissemination of KHA-CARI Guidelines
In order to maximise accessibility to the KHA-CARI guidelines the following dissemination program is used:

• All guidelines are published in supplements to the journal Nephrology (print and web).
• All guidelines are posted on the CARI website with links included on KHA and ANZSN websites.
• Guidelines summaries and links to the guidelines are posted on the US National Guidelines Clearinghouse website.
• Summaries of selected guidelines are written and published in the Australian Family Physician journal.

The KHA-CARI Guidelines are not intended to replace clinical judgement, but rather to complement it.