Introduction
Authors: Bruce F. Culleton
Journal: Journal of the American Society of Nephrology (2006)

In 1999, the Canadian Society of Nephrology (CSN) published clinical practice guidelines (CPG) for the treatment of patients with chronic kidney disease (1,2). In 2003, responding to new evidence and emerging controversies, the CSN Executive Committee recognized the need to update these guidelines and establish new guidelines in areas of perceived clinical need. Updating the hemodialysis guidelines was given high priority. Guidelines for other areas of nephrology, such as peritoneal dialysis, anemia management, and nondialysis chronic kidney disease management, would be developed or revised in a staggered manner over 3 to 5 yr. The overriding objective of the guideline process was to establish national guidelines to improve the quality of health care delivered to patients with chronic kidney disease in Canada. The guidelines that follow are intended to rely on evidence and avoid opinion-based statements where possible. The guidelines are also intended to reflect human and financial resources available throughout Canada at the time of their writing. Methods Guideline Workgroups are directly responsible for the content of each section. A Workgroup Chair is chosen based upon content expertise and participation in the previous CSN CPG. The Workgroup is then populated by nephrologists with recognized content expertise and, when necessary, allied health professionals and/or patient representatives. Workgroups are asked to utilize the extensive content and methodologic review of the relevant literature obtained by the prior CSN guidelines (1) and prior publications of the relevant Kidney Disease Outcomes Quality Initiative (KDOQI) Workgroups (3–7). This literature is supplemented by using two methods to locate additional evidence. First, the Workgroup members use their content expertise to identify new evidence. Second, a focused literature search of English-language nephrology and general medical journals is performed by the content experts. The Workgroups assume that new evidence of sufficient magnitude to warrant the revision of existing national guidelines would be discovered using these two methods. Although this approach might be criticized for lack of methodologic rigor, such an approach is pragmatic and has been utilized and advocated by others (8,9). The grading of the evidence supporting each recommendation is based upon the scheme developed by the Canadian Hypertension Education Program (Figures 1,2, and 3) (10). Recommendations are developed only if they are “strongly recommended” by each Workgroup, i.e., the Workgroup is confident that adherence will do more good than harm. Other status statements within each document are not made. Because of limited trial data within several clinically important areas, the Workgroups may be forced to make limited, opinion-based recommendations. These will be explicitly stated. The distinction between grading of evidence and the perceived importance of each recommendation must not be confused. In this regard, a recommendation receiving a Grade D is just as relevant and important to the Workgroup as a recommendation receiving a Grade A. Finally, in some instances it may not be appropriate to make a recommendation because of lack of agreement between studies or lack of good-quality evidence. In these situations, specific research recommendations will be stated. The hemodialysis Workgroup met initially in May 2004 at the CSN Annual Meeting and again in January 2005. The Chair of the CSN CPG Committee (B. Culleton) and the Chair of the Workgroup (K. Jindal) reviewed and modified the first draft of the hemodialysis guidelines. The document was then formally reviewed by four Canadian nephrologists chosen for their specific research or clinical experience. The document was modified in response to this internal review and a second draft was distributed to all members of the CSN. Comments from this external review were considered in detail and the final revised draft of the hemodialysis guidelines was completed in September 2005. Sponsorship Financial support for the CPG process has been provided by an educational grant from Amgen Canada to the CSN.Figure 1: Algorithm for assigning evidence grades to recommendations.Figure 2: Algorithm for assigning evidence grades to recommendations (continued from Figure 1, for adequate randomized trials, systematic reviews, or subgroup analyses).Figure 3: Algorithm for assigning evidence grades to recommendations (continued from Figure 1, for observational studies).