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## Complete Summary

#### GUIDELINE TITLE

Guidelines for the management of chronic kidney disease in HIV-infected
patients: recommendations of the HIV Medicine Association of the
Infectious Diseases Society of America.

#### BIBLIOGRAPHIC SOURCE(S)

Gupta SK, Eustace JA, Winston JA, Boydstun II, Ahuja TS, Rodriguez RA,
Tashima KT, Roland M, Franceschini N, Palella FJ, Lennox JL, Klotman PE,
Nachman SA, Hall SD, Szczech LA. Guidelines for the management of
chronic kidney disease in HIV-infected patients: recommendations of the
HIV Medicine Association of the Infectious Diseases Society of America.
Clin Infect Dis 2005 Jun 1;40(11):1559-85. \[238 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15889353)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [July 31, 2008, Erythropoiesis Stimulating Agents
    (ESAs)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#ESA2):
    Amgen and the U.S. Food and Drug Administration (FDA) informed
    healthcare professionals of modifications to certain sections of the
    Boxed Warnings, Indications and Usage, and Dosage and Administration
    sections of prescribing information for Erythropoiesis Stimulating
    Agents (ESAs). The changes clarify the FDA-approved conditions for
    use of ESAs in patients with cancer and revise directions for dosing
    to state the hemoglobin level at which treatment with an ESA should
    be initiated.

-   [November 8, 2007 and January 3, 2008 Update, Erythropoiesis
    Stimulating Agents
    (ESAs)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#ESA2):
    The U.S. Food and Drug Administration (FDA) notified healthcare
    professionals of revised boxed warnings and other safety-related
    product labeling changes for erythropoiesis-stimulating agents
    (ESAs) stating serious adverse events, such as tumor growth and
    shortened survival in patients with advanced cancer and chronic
    kidney failure.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Chronic kidney disease

-   Human immunodeficiency virus (HIV) infection

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Screening

#### CLINICAL SPECIALTY

Family Practice\
Hematology\
Infectious Diseases\
Internal Medicine\
Nephrology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Nurses\
Patients\
Physician Assistants\
Physicians

#### GUIDELINE OBJECTIVE(S)

To address the clinical issues involved in both adults and children with
human immunodeficiency virus (HIV)-related renal disease

#### TARGET POPULATION

Human immunodeficiency virus (HIV)-infected patients (adults and
children) with chronic kidney disease

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Screening and Diagnostic Evaluation**

1.  Qualitative assessment for risk of kidney disease (e.g., race,
    family history, CD4^+^ lymphocyte count, human immunodeficiency
    virus \[HIV\]-1 ribonucleic acid \[RNA\] level, history of
    nephrotoxic medications, comorbidities)

2.  Urine analysis for proteinuria

3.  Calculated estimate of renal function (estimation of creatinine
    clearance or glomerular filtration rate)

4.  Annual follow up

5.  Blood pressure measurement

6.  Quantification of proteinuria (albumin-to-creatinine ratio or
    protein-to creatinine-ratio)

7.  Renal ultrasound

8.  Renal biopsy

**Management/Treatment**

1.  Referral to nephrologist

2.  Control of hypertension

    -   Angiotensin-converting enzyme (ACE) inhibitors

    -   Angiotensin receptor blockers (ARBs)

3.  Dialysis

4.  Arteriovenous fistulae placement

5.  Renal transplantation

6.  Highly active antiretroviral therapy (HAART)

7.  Prednisone

8.  Adjustment of antiretroviral medication and antimicrobial agent
    dosing

9.  Use of recombinant human erythropoietin

10. Use of 1,25-dihydroxy vitamin D3 or its analogues

11. Hepatitis B vaccination (Recombivax HB, Engerix B) and checking of
    anti-hepatitis B surface antigen titers following vaccination

12. *Streptococcus pneumoniae* vaccination (Pneumovax, Pnu-imune 23)

13. Influenza virus vaccination

14. Hepatitis A vaccination

#### MAJOR OUTCOMES CONSIDERED

-   Renal function

-   Side effects of medications

-   Incidence of chronic kidney disease

-   Incidence of human immunodeficiency virus (HIV)-associated
    nephropathy

-   Survival

-   Morbidity and mortality

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence for these guidelines was collected using MEDLINE searches
of the relevant literature and reviews of pertinent abstracts (all in
the English language) presented at both major infectious diseases and
nephrology society meetings from January 2000 through February 2004.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Quality of Evidence**

I.  Evidence from at least one properly randomized, controlled trial

II. Evidence from at least one well-designed clinical trial without
    randomization, from cohort or case-controlled analytic studies
    (preferably from more than one center), from multiple time-series
    studies, or from dramatic results of uncontrolled experiments

III. Evidence from opinions of respected authorities based on clinical
     experience, descriptive studies, or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Strength of Recommendation**

A.  Good evidence to support a recommendation for use

B.  Moderate evidence to support a recommendation for use

C.  Poor evidence to support a recommendation

D.  Moderate evidence to support a recommendation against use

E.  Good evidence to support a recommendation against use

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions of the levels of evidence **(I-III)** and grades of
recommendation **(A-E)** are repeated at the end of the Major
Recommendations field.

**[Screening and Initial Evaluations]{.underline}**

All patients at the time of human immunodeficiency virus (HIV) diagnosis
should be assessed for existing kidney disease with a screening urine
analysis for proteinuria and a calculated estimate of renal function
**(C-III)**.

If there is no evidence of proteinuria at initial evaluation, patients
at high risk for the development of proteinuric renal disease (i.e.,
African American persons, those with CD4^+^ cell counts \<200 microL or
HIV RNA levels \>4,000 copies/mL, and those with diabetes mellitus,
hypertension, or hepatitis C virus coinfection) should undergo annual
screening **(B-II)**. Renal function should be estimated on a yearly
basis to assess for changes over time **(B-II)**.

Additional evaluations (including quantification of proteinuria, renal
ultrasound, and potentially renal biopsy) and referral to a nephrologist
are recommended for patients with proteinuria of grade
[\>]{.underline}1+ by dipstick analysis or glomerular filtration rate
(GFR) \<60 mL/min per 1.73 m^2^ **(B-II)**.

**[Management]{.underline}**

In HIV-infected patients with evidence of nephropathy, blood pressure
should be controlled to a level no higher than 125/75 mm Hg **(B-III)**,
with the initial preferential use of angiotensin-converting enzyme (ACE)
inhibitors or angiotensin receptor blockers (ARBs) for those patients
with proteinuria **(B-II)**. Calcium channel blockers should be avoided
in patients receiving protease inhibitors **(D-II)**.

Dialysis and the placement of arteriovenous fistulae (native fistulae
preferred **\[A-II\]**) should not be withheld for patients solely
because of HIV infection **(A-II)**

Renal transplantation may be considered for patients with end-stage
renal disease (ESRD) if provided in a supervised clinical trial or at
centers with adequate experience in this area **(C-III)**.

Patients with HIV-associated nephropathy (HIVAN) should be treated with
highly active antiretroviral therapy (HAART) at diagnosis **(B-II)**.
HAART should not be withheld from patients simply because of the
severity of their renal dysfunction **(B-III)**.

Addition of ACE inhibitors, ARBs, and/or prednisone should be considered
in patients with HIVAN if HAART alone does not result in improvement of
renal function **(B-II)**.

**[Antiretroviral Dosing And Renal Toxicities]{.underline}**

Appropriate reduction of dosing for antiretrovirals that are primarily
renally eliminated is warranted **(C-III)**, with additional doses given
after hemodialysis for those drugs that are readily removed by dialysis
**(B-II)**.

Nucleoside analogues should not be withheld in patients with reduced
renal function for fear of the development of lactic acidosis
**(D-III)**.

Patients receiving indinavir should drink at least 1.5 L of water daily
to prevent stone formation **(B-III)**. Periodic monitoring of renal
function and pyuria should be performed during the first 6 months of
indinavir therapy and biannually thereafter **(B-II)**, although routine
screening for crystalluria is not warranted unless there is a suspicion
of nephrolithiasis **(B-II)**. Indinavir need not be withheld from
patients with reduced renal function **(C-III)**. In patients who
develop indinavir nephrolithiasis, it would be reasonable to restart
indinavir therapy once rehydration is achieved **(B-III)**. Patients who
develop indinavir-induced hypertension, pyuria, rhabdomyolysis, or renal
insufficiency (acute or chronic) should permanently discontinue use of
this drug **(B-III)**.

Patients receiving tenofovir who have a GFR \<90 mL/min per 1.73 m^2^,
patients receiving other medications eliminated via renal secretion
(e.g., adefovir, acyclovir, ganciclovir, or cidofovir), patients with
other comorbid diseases (e.g., diabetes or hypertension), or patients
receiving ritonavir-boosted protease inhibitor regimens should be
monitored at least biannually for measurements of renal function, serum
phosphorus, and urine analysis for proteinuria and glycosuria
**(B-III)**.

**HIV Antiretroviral Dosing Recommendations**

A summary of dosing recommendations for patients with chronic kidney
disease (CKD)/ESRD is provided in Table 3 of the original guideline
document.

**Renal Dosing of Antibiotics Commonly Used in HIV Care**

Many of the antimicrobials commonly used to prevent and treat
opportunistic infections such as *Pneumocystis jiroveci* pneumonia,
*Toxoplasma* encephalitis, and *Mycobacterium avium intracellulare*
infections require dose reduction in the HIV-infected patient with CKD
because of their renal elimination. Recommended dosing data for these
drugs are available in Table 4 of the original guideline document.

**[HIV Infection And CKD in the Pediatric and Adolescent
Populations]{.underline}**

In children without evidence of existing renal disease, screening
evaluation for the development of HIVAN is similar to that proposed
earlier for adults and should include complete urinalysis and testing to
determine serum electrolyte levels, blood urea nitrogen levels, and
creatinine levels every 6 months **(C-III)**.

Pediatric HIVAN and other proteinuric nephropathies in HIV-infected
children should be treated with HAART; referral to a nephrologist and
the addition of ACE-inhibition should also be considered for patients
with more severe proteinuria (grade [\>]{.underline}1+ by urine dipstick
analysis or a protein-to-creatinine ratio [\>]{.underline}0.2 g/g for 3
separate specimens) **(C-III)**. Steroid use is not recommended for this
population **(D-II)**.

**[Special Topics]{.underline}**

Use of recombinant human erythropoietin should be considered in patients
with hemoglobin levels 2 g/dL less than the lower limit of normal; the
therapeutic hemoglobin target is a hemoglobin level of 11 to 12 g/dL
**(C-III)**.

Analogous to the general population with CKD, all HIV-infected ESRD
patients with secondary hyperparathyroidism (serum calcium level, \<9.5
mg/dL; serum phosphorus level, \<4.6 mg/dL; and serum parathyroid
hormone level, \>35 pcg/mL) should be treated with 1,25-dihydroxy
vitamin D3 or its analogues **(C-III)**.

HIV-infected patients requiring hemodialysis should have anti-HBs titers
checked after receiving a standard primary series of 3 hepatitis B
vaccinations and should receive a fourth injection if these titers are
\<10 IU/L **(B-II)**.

**Vaccinations Recommended for HIV-Infected Adults with Chronic Kidney
Disease**

  ----------------------------------------------------------------------------
  **Pathogen**         **Recommendation(s)**
  -------------------- -------------------------------------------------------
  ***Streptococcus     Pneumovax^a^ or Pnu-Imune^b^ 23 administered in a
  pneumoniae***        single 0.5-mL subcutaneous or intramuscular dose if
                       CD4^+^ cell count [\>]{.underline}200 cells/mm^3^.
                       Additional vaccination is recommended for patients
                       initially vaccinated at a CD4^+^ count \<200
                       cells/mm^3^ whose CD4^+^ count increases to
                       [\>]{.underline}200 cells/mm^3^. It is preferable to
                       vaccinate such individuals before development of
                       end-stage renal disease. Patients should be
                       revaccinated after 5 years.

  **Influenza virus**  All patients should be vaccinated annually.

  **Hepatitis A        Patients who are negative for anti-hepatitis A virus
  virus**              and patients at increased risk for hepatitis A virus
                       infection (e.g., illicit drug users, men who have sex
                       with men, and patients with chronic liver disease
                       \[including chronic hepatitis B or hepatitis C\])
                       should be vaccinated.

  **Hepatitis B        
  virus**              

  *Patients of all     For monitoring, check antibody to hepatitis B surface
  ages*                antigen (anti-HBs) titers 1-2 months after the last
                       primary vaccine dose is administered (an adequate
                       response is [\>]{.underline}10 mIU/mL). Revaccinate
                       those patients who do not respond with 3 doses. For
                       those patients who do respond, follow anti-HBs levels
                       semiannually; if anti-HBs levels are \<10 mIU/mL,
                       administer a booster dose.

  *Patients aged       Administer Recombivax HB^a^ at a dose of 10 micrograms
  [\>]{.underline}20   at 0, 1, and 6 months or Engerix-B^c^ at a dose of 20
  years*\              micrograms intramuscularly (im) at 0, 1, and 6 months.\
  \                    \
  Predialysis\         Administer Recombivax HB^a^ at a dose of 40 micrograms
  \                    at 0, 1, and 6 months or Engerix-B^c^ at a dose of 40
  \                    micrograms im at 0, 1, and 6 months.
  Dialysis dependent   

  *Patients aged \<20  Administer Recombivax HB^a^ at a dose of 5 micrograms
  years*               at 0, 1, and 6 months or Engerix-B^c^ at a dose of 10
                       micrograms im at 0, 1, and 6 months.
  ----------------------------------------------------------------------------

^a^Merck\
^b^Lederle\
^c^SmithKline Beecham Biologicals

**[Definitions]{.underline}**

**Quality of Evidence**

I.  Evidence from at least one properly randomized, controlled trial

II. Evidence from at least one well-designed clinical trial without
    randomization, from cohort or case-control analytic studies
    (preferably from more than one center), from multiple time-series
    studies, or from dramatic results of uncontrolled experiments

III. Evidence from opinions of respected authorities based on clinical
     experience, descriptive studies, or reports of expert committees

**Strength of Recommendations**

A.  Good evidence to support a recommendation for use

B.  Moderate evidence to support a recommendation for use

C.  Poor evidence to support a recommendation

D.  Moderate evidence to support a recommendation against use

E.  Good evidence to support a recommendation against use

#### CLINICAL ALGORITHM(S)

A clinical algorithm is provided in the original guideline document for
\"Screening for Human Immunodeficiency Virus (HIV}-related Renal
Disease.\"

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Identification of human immunodeficiency virus (HIV)-infected patients
at risk for renal disease may help clinicians implement potentially
preventative and therapeutic strategies.

#### POTENTIAL HARMS

-   Calcium channel blockers of both the dihydropyridine and
    nondihydropyridine classes should be used with caution because of
    their potential interaction with protease inhibitors, which can
    result in hypotension and possibly in conduction delays.

-   Peritonitis has been reported in several small series of
    HIV-infected patients receiving peritoneal dialysis.

-   Solid-organ transplantation in HIV-infected patients is complicated
    by drug interactions and a complex set of infectious, metabolic, and
    neoplastic complications related to each condition. Clinical
    management must be provided by a multidisciplinary team of providers
    who are able to communicate rapidly about evolving signs, symptoms,
    and laboratory abnormalities.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Underlying infection would be a contraindication for
    immunosuppressive therapy.

-   Cidofovir is contraindicated in patients with preexisting creatinine
    clearance of \<55 mL/min or a urine protein level [\>]{.underline}2+
    (100 mg/dL) on urine dipstick.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Guidelines are written to improve the quality of care, to improve
    the appropriateness of care, to improve cost-effectiveness, and to
    serve as educational tools. The goal is not to create standards of
    care; however, other organizations may choose to adopt these
    guidelines or components thereof for such purposes. Practice
    guidelines, however, are never a substitute for clinical judgment.
    Clinical discretion is of the utmost importance in the application
    of a guideline to individual patients, because no guideline can ever
    be specific enough to be applied in all situations.

-   Although the authors feel that these recommendations should
    generally apply to all human immunodeficiency virus (HIV)-infected
    patients, it is understood that providers need to tailor these
    guidelines around the needs and circumstances of the individual
    patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Gupta SK, Eustace JA, Winston JA, Boydstun II, Ahuja TS, Rodriguez RA,
Tashima KT, Roland M, Franceschini N, Palella FJ, Lennox JL, Klotman PE,
Nachman SA, Hall SD, Szczech LA. Guidelines for the management of
chronic kidney disease in HIV-infected patients: recommendations of the
HIV Medicine Association of the Infectious Diseases Society of America.
Clin Infect Dis 2005 Jun 1;40(11):1559-85. \[238 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15889353)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2005 Jun 1

#### GUIDELINE DEVELOPER(S)

Infectious Diseases Society of America - Medical Specialty Society

#### SOURCE(S) OF FUNDING

Infectious Diseases Society of America (IDSA)

#### GUIDELINE COMMITTEE

Infectious Diseases Society of America (IDSA) Practice Guidelines
Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Authors*: Samir K. Gupta, Division of Infectious Diseases, Department
of Medicine, Indiana University School of Medicine, Indianapolis; Joseph
A. Eustace, Division of Nephrology, Johns Hopkins University, School of
Medicine and Department of Epidemiology, Bloomberg School of Public
Health, Baltimore, Maryland; Jonathan A. Winston, Division of
Nephrology, Department of Medicine, Mount Sinai School of Medicine, New
York; Ivy I. Boydstun, Division of Nephrology and Hypertension; Tejinder
S. Ahuja, Division of Nephrology, Department of Medicine, University of
Texas Medical Branch, Galveston; Rudolph A. Rodriguez, Division of
Nephrology, Department of Medicine, San Francisco General Hospital;
Karen T. Tashima, Division of Infectious Diseases, Department of
Medicine, The Miriam Hospital, Brown Medical School, Providence, Rhode
Island; Michelle Roland, Positive Health Program at San Francisco
General Hospital and the UCSF AIDS Research Institute, Department of
Medicine, University of California at San Francisco; Nora Franceschini,
Division of Nephrology and Hypertension, Department of Medicine,
University of North Carolina at Chapel Hill, Frank J. Palella, Division
of Infectious Diseases, Department of Medicine, Northwestern University
Feinberg School of Medicine, Chicago, Illinois; Jeffrey L. Lennox, Grady
Infectious Disease Program, Division of Infectious Diseases, Department
of Medicine, Emory University, Atlanta, Georgia; Paul E. Klotman,
Division of Nephrology, Department of Medicine, Mount Sinai School of
Medicine, New York; Sharon A. Nachman, Division of Infectious Diseases,
Department of Pediatrics, State University of New York, Stony Brook;
Stephen D. Hall, Division of Clinical Pharmacology, Department of
Medicine, Indiana University School of Medicine, Indianapolis; Lynda A.
Szczech, Duke Clinical Research Institute and the Division of
Nephrology, Department of Medicine, Duke University Medical Center,
Durham, North Carolina

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

S.K.G. has received honoraria from Gilead Sciences. T.S.A. has received
speaker bureau fees and funding from Genzyme. K.T.T. has received grant
support and honoraria from Glaxo-SmithKline, Bristol-Myers Squibb,
Gilead Sciences, and Merck. M.R. has received grant support from
GlaxoSmithKline, Bristol-Myers Squibb, and Agouron Pharmaceuticals and
has received honoraria from Gilead Sciences and Boehringer Ingelheim.
F.J.P. has received honoraria from Bristol Myers Squibb, Roche
Pharmaceuticals, Gilead Sciences, and Agouron Pharmaceuticals. J.L.L.
has received grant support and honoraria from Gilead Sciences, Tibotec
Pharmaceuticals, Abbott Laboratories, Merck, and Bristol- Myers Squibb.
All other authors: no conflicts.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Infectious Disease Society of
America (IDSA) Web
site](http://www.journals.uchicago.edu/cgi-bin/resolve?CID36426).

Print copies: Available from Infectious Diseases Society of America,
1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Kish MA. Guide to development of practice guidelines. Clin Infect
    Dis 2001 Mar 15;32(6):851-4.

Electronic copies: Available from the [Clinical Infectious Diseases
Journal Web
site](http://www.journals.uchicago.edu/doi/full/10.1086/319366).

Print copies: Available from Infectious Diseases Society of America,
1300 Wilson Boulevard, Suite 300, Arlington, VA 22209.

A PDA version of the original guideline document is available from
[www.idsaguidelinesforhandhelds.org](http://www.idsaguidelinesforhandhelds.org/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 19, 2005. This summary was
updated by ECRI on January 29, 2007, following the U.S. Food and Drug
Administration advisory on erythropoiesis stimulating agents. This
summary was updated by ECRI Institute on July 9, 2007, following the FDA
advisory on erythropoiesis stimulating agents. This summary was updated
by ECRI Institute on March 21, 2008 following the FDA advisory on
Erythropoiesis Stimulating Agents. This summary was updated by ECRI
Institute on August 15, 2008 following the U.S. Food and Drug
Administration advisory on Erythropoiesis Stimulating Agents (ESAs).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which may be
subject to the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008