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INTRODUCTION: The Canadian Society of Nephrology (CSN) was established to promote the highest quality of care for patients with renal diseases and to encourage research related to the kidney and its disorders. The CSN Clinical Practice Guideline (CPG) Committee develops guidelines with clear recommendations to influence physicians' practice and improve the health of patients with kidney disease in Canada. REVIEW: In this review we describe the CSN process in prioritizing CPGs topics. We document the CSN experience using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We then detail the CSN process in developing de novo CPGs and in adapting existing CPGs and developing accompanying commentaries. We also discuss challenges faced during this process and suggest solutions. Furthermore, we summarize the CSN effort in disseminating and implementing their guidelines. Additionally, we describe recent development and partnerships that allow evaluation of the effect of the CSN guidelines and commentaries. CONCLUSION: The CSN follows a comprehensive process in identifying priority areas to be addressed in CPGs. In 2010, the CSN adopted GRADE, which enhanced the rigor and transparency of guideline development. This process focuses on systematically identifying best available evidence and carefully assessing its quality, balancing benefits and harms, considering patients' and societies' values and preferences, and when possible considering resource implications. Recent partnership allows wider dissemination and implementation among end users and evaluation of the effects of CPG and commentaries on the health of Canadians.
INTRODUCTION: La mission de la Société canadienne de néphrologie (SCN) est de promouvoir des soins de grande qualité aux patients atteints de maladies rénales et d'encourager la recherche en néphrologie. Le comité des guides de pratique clinique (GPC) de la SCN a pour objectif le développement de lignes directrices comportant des recommandations claires de façon à influencer la pratique médicale et d'améliorer le bien-être des patients atteints de maladies rénales au Canada. REVUE: Dans cette publication, nous décrivons l'approche utilisée par la SCN dans la priorisation des différents sujets abordés dans les GPC. Nous abordons l'expérience de la SCN avec l'utilisation de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Nous détaillons également le processus utilisé par la SCN dans le développement de nouveaux GPC et dans la modification des GPC existants. Nous discutons des difficultés rencontrées lors de ce processus tout en suggérant des solutions. Nous résumons les efforts encourus par la SCN pour la diffusion et l'application des lignes directrices. Finalement, nous décrivons les récentes collaborations de la SCN permettant l'évaluation de l'impact des lignes directrices de la SCN. CONCLUSION: La SCN suit un processus rigoureux dans l'identification des priorités à aborder dans les GPC. Depuis 2010, la SCN a décidé d'adopter l'approche GRADE pour faire preuve de plus de rigueur et de transparence dans l'élaboration de lignes directrices. Cette approche consiste à identifier toutes les évidences en étudiant leur qualité, en mesurant les risques et les bénéfices, en considérant les valeurs et les préférences pour les patients ainsi que la société et en tenant compte des ressources disponibles. Le partenariat permet une plus grande diffusion des guides de pratique et une évaluation des effets des GPC sur la santé des canadiens.
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PURPOSE: Our objective was to describe the current practice for initiation of RRT in this population. There is uncertainty regarding the optimal time to initiate renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI). METHODS: Prospective study of patients receiving RRT in 6 intensive care units (ICUs) at 3 hospitals from July 2007 to August 2008. We characterized factors associated with start of RRT and evaluated their relationship with mortality. RESULTS: We included 234 patients. RRT was initiated 1 day (0-4) after ICU admission (median [interquartile range]). Median creatinine was 331 µmol/L (225-446 µmol/L), urea 22.9 mmol/L (13.9-32.9 mmol/L), and RIFLE-Failure in 76.9%. Of traditional indications, Pao(2)/Fio(2) < 200 (54.5%) and oliguria (32.9%) were most common. ICU and hospital mortality were 45.3% and 51.9%, respectively. In adjusted analysis, mortality at RRT initiation was associated with creatinine <332 µmol/L (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.5-5.4), change in urea from admission >8.9 mmol/L (OR 1.8; 95% CI, 1.0-3.4), urine output <82 mL/24 hours (OR 3.0; 95% CI, 1.4-6.5), fluid balance >3.0 L/24 hours (OR 2.3; 95% CI, 1.2-4.5), percentage of fluid overload >5% (OR 2.3; 95% CI, 1.2-4.7), 3 or more failing organs (OR 4.5; 95% CI, 1.2-4.2), Sequential Organ Failure Assessment score >14 (OR 2.3; 95% CI, 1.3-4.3), and start 4 days or more after admission (OR 4.3; 95% CI, 1.9-9.5). Mortality was higher as factors accumulated. CONCLUSION: In ICU patients requiring RRT, there was marked variation in factors that influence start of RRT. RRT initiation with fewer clinical triggers was associated with lower mortality. Timing of RRT may modify survival but requires appraisal in a randomized trial.