Clinical Practice Guidelines

KDIGO Guideline for Glomerulonephritis

The Work Group developing the KDIGO Clinical Practice Guideline on Glomerulonephritis is chaired by Drs. Daniel Cattran and John Feehally. It is anticipated that this guideline will publish in the first half of 2011.

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Guideline Workgroup Roster

NAME/AFFILIATION	CONTACT INFORMATION
Co–Chair: Daniel C Cattran, FRCPC, MD Senior Scientist Division of Clinical Investigation & Human Physiology Toronto General Research Institute (TGRI)	Toronto General Hospital Eaton North Wing 2nd Floor Rm. 2E228 200 Elizabeth St. Toronto, Ontario M5G 2C4, CANADA
Co Chair: John Feehally, MBBS, DM, FRCP Professor & Consultant Nephrologist University Hospitals of Leicester Honorary Professor of Renal Medicine University of Leicester	The John Walls Renal Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 4 PW, UNITED KINGDOM
H Terence Cook, MBBS Professor of Renal Pathology Imperial College London	Department of Histopathology Hammersmith Hospital, DuCane Rd, W12 0NN, London UNITED KINGDOM
Fernando C Fervenza, MD, PhD Mayo Clinic	Department of Nephrology and Hypertension 200 First St SW, Rochester, MN 55905 USA
Jürgen Floege, MD Medizinische Klinik II	Div. Nephrology and Clinical Immunology University hospital, RWTH Aachen Pauwelsstr. 30 52057 Aachen GERMANY
Debbie Gipson, MD, MS Associate Professor Pediatric Nephrology University of Michigan	Division of Nephrology Department of Pediatrics CS Mott Children’s Hospital, F6865 1500 E. Medical Center Drive, SPC 5297 Ann Arbor, MI 48109–5297 USA
Richard J Glassock, MD, MACP Emeritus Professor of Medicine The Geffen School of Medicine at UCLA	8 Bethany, Laguna Niguel, CA 92677 USA
Elisabeth M Hodson, MBBS, FRACP Co–Chair Medicine Clinical, Consultant Physician in Pediatric Nephrology Cochrane Renal Group Centre for Kidney Research The Children’s Hospital at Westmead	Locked Bag 4001, NSW 2145, Westmead, AUSTRALIA
Vivekanand Jha, MD, FRCP Additional Professor of Nephrology Postgraduate Institute of Medical Education	#126A Sector 24 Chandigarh 160 023 INDIA
Philip K T Li, MD, FRCP, FACP Chief of Nephrology & Consultant Physician Honorary Professor of Medicine Prince of Wales Hospital Chinese University of Hong Kong	Department of Medicine & Therapeutics 30–32 Ngan Shing St. Shatin, Hong Kong CHINA
Zhi–Hong Liu, MD Professor of Medicine Nanjing University School of Medicine Research Institute of Nephrology Jinling Hospital President elect, Chinese Society of Nephrology	305 East Zhong Shan Road Nanjing 210002 CHINA
Sergio A Mezzano, MD Universidad Austral	Universidad Austral Bueras No. 884, B–D Valdivia, X Region CHILE
Patrick H Nachman, MD Associate Professor of Medicine UNC Kidney Center	University of North Carolina, Chapel Hill, NC 27599 USA
Manuel Praga, MD Hospital 12 de Octubre	Servicio de Nefrología Avda. de Córdoba, s/n 28041 Madrid SPAIN
Jai Radhakrishnan, MD, MRCP Associate Professor of Clinical Medicine New York Presbyterian–Columbia	Presbyterian Hospital Room 4–124 622 West 168th St. New York, NY 10032 USA
Brad H Rovin, MD, FACP, FASN Professor of Medicine and Pathology Vice Chairman of Research for Internal Medicine Director, Division of Nephrology Director, Fellowship Program in Nephrology Director, Acute Dialysis Programs, University Hospitals The Ohio State University College of Medicine	Ohio State University Nephrology, 395 W 12th Ave, Ground Floor, Columbus, OH 43210. USA
Stéphan Troyanov, MD Hôpital du Sacré–Coeur in Montreal
Jack Wetzels, MD, PhD Professor of Nephrology Radboud University Nijmegen Medical Center	Dept of Nephrology Radboud University Nijmegen Medical Center PO Box 9101 6500 HB Nijmegen The Netherlands

Guideline Scope

RATIONALE

Glomerulonephritis [GN] is a global health problem. Glomerulonephritis is a common cause of chronic kidney disease and a global threat to public health due to its increasing incidence, poor outcomes, and high associated costs. Throughout the world, treatment of end–stage renal disease (ESRD) poses a major challenge for the health care system and dialysis costs alone consume over 5% of annual health care expenditures in Canada. In addition to direct health care costs, ESRD caused by glomerulonephritis most commonly affect people during the most productive period of their lives, the second to fifth decades, when the socioeconomic impact on patients and families is devastating. Preservation of kidney function in patients with glomerulonephritis and prevention of progression to ESRD are currently identified as a main priority for global nephrology care.

Etiologies and patterns of GN vary substantially around the world – for example GN associated with infection has high prevalence in many parts of the emerging world, although reducing prevalence in the developed world; and common patterns of ‘primary’ GN vary significantly in prevalence among different geographical regions and in different racial groups. But regardless of these variations, GN remains a major cause of morbidity and mortality all over the world and is probably underrepresented in most ESRD registries because of low detection rates and/or because some renal registries base diagnostic definitions purely on clinical presentation.. Clinical presentations of GN vary widely. Some people with GN are asymptomatic for long periods of time unless opportunistic testing identifies abnormal urinalysis or hypertension. Others develop an acute clinical illness – for example nephritic syndrome, nephrotic syndrome, visible haematuria, or acute kidney injury. Others present with slowly progressive proteinuric and/or hypertension associated CKD.

The burden of GN is most significant in developing countries with limited resources for the care of these patients if ESRD cannot be avoided. Addressing the unique circumstances and needs of developing countries, especially in the prevention, detection and management of GN in its early and potentially reversible stages is of paramount importance. Even in the developed world the escalating costs of renal replacement therapy is rapidly increasing and is significantly related to the patient population with glomerulonephritis, since their survival on dialysis is 4-5 times that of multisystem causes of ESRD like diabetes.

Apart from treatment strategies aimed at eliminating a primary causative agent [for example infection], the most common specific treatment approaches include administration of agents designed to suppress or otherwise modify the immune system. The quality of evidence available to evaluate these treatments is variable.

Evidence-based clinical practice guidelines for the diagnosis, evaluation, classification, prevention, and management of GN can lead to improved outcomes. This work will also facilitate and identify research questions focused on a the major gaps in the current management of these disorders.

At its meeting in December 2008 the KDIGO Board determined that glomerulonephritis meets several criteria for developing clinical practice guidelines.

1. It is prevalent.
2. It is amenable to earlier detection and intervention.
3. It imposes a heavy burden of illness (morbidity and mortality)
4. Its incidence and prevalence in the pediatric and young adult age groups produces immense social and financial hardship not only on the patient but their families.
5. The cost per person of managing the disease is high, especially if ESRD is not prevented.
6. There is considerable clinical practice variability in diagnosis and treatment
7. A clinical practice guideline has the potential to reduce this variability, improve patient outcomes, and reduce individual and societal costs.

GUIDING PRINCIPLES AND PROCESS

• Scientific and methodological rigor using an evidence-based approach
• Interdisciplinary approach. Work Group members will be chosen for their clinical expertise in the field of glomerular disease, their commitment to quality of care and their capacity for collaborative partnership working.
• Independence of Work Groups. The work group will have independence and final responsibility in the formulation of recommendations. This will assure an unbiased approach to guideline development, without influence of organizations or industry
• Openness of the guideline development process. Following their initial review by KDIGO Executive Committee and Board, the draft guideline will be subjected to a public review process that invites comment from groups and professionals whom the guideline will affect. Comments submitted at each phase of review will be carefully considered by the Work Group prior to publication of the final guideline.

KDIGO will convene a Work Group, with its first meeting to take place May 2-3 2009. The Work Group will be charged with developing a clinical practice guideline for the diagnosis, evaluation, classification, prevention and management of glomerulonephritis.

SCOPE

1. Diagnosis and treatment of common patterns of primary glomerulonephritis in adults & children, including:
   • Minimal change disease
   • Focal segmental glomerulosclerosis
   • Membranous nephropathy
   • Membranoproliferative [mesangiocapillary] glomerulonephritis
   • IGA nephropathy
   • Infection related glomerulonephritis – including post–infectious GN and glomerular disease related to HBV, HCV, HIV infection
2. Diagnosis and treatment of systemic immune disease in adults & children with glomerular or renovascular (?) involvement, including:
   • [a] Lupus nephritis
   • [b] Renal vasculitis
   • [c] Goodpasture’s disease

OUT OF SCOPE

1. Management of complications and risk factors for progression common to all proteinuric kidney diseases – including nephrotic syndrome, hypertension, proteinuria, and dyslipidaemia.
2. Glomerular diseases associated with systemic disorders which do not have disease mechanisms founded in disordered immunity – including diabetic nephropathy, thrombotic microangiopathy, and amyloidosis.

RESEARCH RECOMMENDATIONS

The evidence review process and the expertise of the Work Group will be utilized to identify gaps in knowledge regarding the diagnosis, evaluation, classification, prevention and management of glomerulonephritis and make research recommendations for implementation subsequent to the release of the guidelines.