GRADE system of grading new clinical guidelines for nephrology

From Kidney International

Grading Evidence and Recommendations for Clinical Practice Guidelines in Nephrology. A Position Statement From Kidney Disease: Improving Global Outcomes (KDIGO)

Posted 01/12/2007

K Uhlig; A MacLeod; J Craig; J Lau;, A S Levey; A Levin; L Moist; E Steinberg; R Walker; C Wanner; N Lameire; G Eknoyan

Abstract

Considerable variation in grading systems used to rate the strength of guideline recommendations and the quality of the supporting evidence in Nephrology highlights the need for a uniform, internationally accepted, rigorous system. In 2004, Kidney Disease: Improving Global Outcomes (KDIGO) commissioned a methods expert group to recommend an approach for grading in future nephrology guidelines.

This position statement by KDIGO recommends adopting the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for the grading of evidence and guidelines on interventions. The GRADE approach appraises systematic reviews of the benefits and harms of an intervention to determine its net health benefit.

The system considers the design, quality, and quantity of studies as well as the consistency and directness of findings when grading the quality of evidence. The strength of the recommendation builds on the quality of the evidence and additional considerations including costs.

The recommendations made by the ERG were then reviewed and adopted by the KDIGO Board of Directors as a position statement on guideline development. The position statement has also been reviewed by representatives for Caring for Australasians with Renal Impairment, United Kingdom Renal Association, European Best Practice Guidelines, Canadian Society of Nephrology, and Kidney Disease Outcomes Quality Initiative.
----------------------
The above mentioned guidelines can be viewed in a table form at the following link -
http://www.medscape.com/viewarticle/550140_Tables#T1
----------------------
The GRADE system assigns separate grades for the quality of evidence and for the strength of recommendations.
It is suitable for questions that address the efficacy of clinical interventions and incorporates summary effect estimates from meta-analyses.
The quality of the evidence is defined as the extent to which 'one can be confident that an estimate of effect or association can be correct'. This is based on the likelihood that further targeted research would not change confidence in the estimate. The strength of recommendation indicates 'the extent of the grader's confidence that adherence to the recommendation will do more good than harm'.
Table 3 shows the sequential process recommended by GRADE for guideline development. Steps 1-3 describe the process that is followed for conducting the systematic reviews and for tabulating data in evidence profiles. Evidence profiles provide a summary of the effects for each important outcome and record the decision making for each step of grading and synthesis.
Steps 4-7 describe how to grade the quality of the evidence and to assess the net health benefit. Steps 8 and 9 describe how to determine whether to issue a recommendation and of what strength.