International Urology and Nephrology

, Volume 49, Issue 2, pp 273–284 | Cite as

A critical appraisal of chronic kidney disease mineral and bone disorders clinical practice guidelines using the AGREE II instrument

  • Nigar SekerciogluEmail author
  • Reem Al-Khalifah
  • Joycelyne Efua Ewusie
  • Rosilene M. Elias
  • Lehana Thabane
  • Jason W. Busse
  • Noori Akhtar-Danesh
  • Alfonso Iorio
  • Tetsuya Isayama
  • Juan Pablo Díaz Martínez
  • Ivan D. Florez
  • Gordon H. Guyatt
Nephrology – Review



Patients with chronic kidney disease mineral and bone disorders (CKD-MBD) suffer high rates of morbidity and mortality, in particular related to bone and cardiovascular outcomes. The management of CKD-MBD remains challenging. The objective of this systematic survey is to critically appraise clinical practice guidelines (CPGs) addressing CKD-MBD.


Data sources included MEDLINE, EMBASE, the National Guideline Clearinghouse, Guideline International Network and Turning Research into Practice up to May 2016. Teams of two reviewers, independently and in duplicate, screened titles and abstracts and potentially eligible full text reports to determine eligibility and subsequently appraised the guidelines using the Advancing Guideline Development, Reporting and Evaluation in Health Care instrument II (AGREE).


Sixteen CPGs published from 2003 to 2015 addressing the diagnosis and management of CKD-MBD in adult patients (11 English, two Spanish, one Italian, one Portuguese and one Slovak) proved eligible. The National Institute for Health and Care Excellence guideline performed best with respect to AGREE II criteria; only three other CPGs warranted high scores on all domains. All other guidelines received scores of under 60% on one or more domains. Major discrepancies in recommendations were not, however, present, and we found no association between quality of CPGs which was not associated with resulting recommendations.


Most guidelines assessing CKD-MBD suffer from serious shortcomings using AGREE criteria although limitations with respect to AGREE criteria do not necessarily lead to inappropriate recommendations.


Chronic kidney disease Advancing guideline development Reporting and evaluation in health care instrument Clinical practice guidelines Mineral and bone disorder 


Compliance with ethical standards

Conflict of interest

Authors have no conflict of interest.

Human rights and animal statement

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

11255_2016_1436_MOESM1_ESM.docx (303 kb)
Supplementary material 1 (DOCX 303 kb)


  1. 1.
    Jha V, Garcia-Garcia G, Iseki K et al (2013) Chronic kidney disease: global dimension and perspectives. Lancet 382(9888):260–272CrossRefPubMedGoogle Scholar
  2. 2.
    National Institutes of Health NIoDaDaKD (2015) United States renal data system. 2015 USRDS annual data report: epidemiology of kidney disease in the United States. United States Renal Data System, BathesdaGoogle Scholar
  3. 3.
    Smith DH, Gullion CM, Nichols G, Keith DS, Brown JB (2004) Cost of medical care for chronic kidney disease and comorbidity among enrollees in a large HMO population. J Am Soc Nephrol: JASN 15(5):1300–1306CrossRefPubMedGoogle Scholar
  4. 4.
    Levey AS, Atkins R, Coresh J et al (2007) Chronic kidney disease as a global public health problem: approaches and initiatives—a position statement from kidney disease improving global outcomes. Kidney Int 72(3):247–259CrossRefPubMedGoogle Scholar
  5. 5.
    Cortes-Sanabria L, Rodriguez-Arreola BE, Ortiz-Juarez VR et al (2013) Comparison of direct medical costs between automated and continuous ambulatory peritoneal dialysis. Perit Dial Int: J Int Soc Perit Dial 33(6):679–686CrossRefGoogle Scholar
  6. 6.
    Suja A, Anju R, Anju V, Neethu J, Peeyush P, Saraswathy R (2012) Economic evaluation of end stage renal disease patients undergoing hemodialysis. J Pharm Bioallied Sci 4(2):107–111CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Laliberte F, Bookhart BK, Vekeman F et al (2009) Direct all-cause health care costs associated with chronic kidney disease in patients with diabetes and hypertension: a managed care perspective. J Manag Care Pharm: JMCP 15(4):312–322PubMedGoogle Scholar
  8. 8.
    Group KDIGOKCW: KDIGO (2012) Clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int 2013(3):1–150Google Scholar
  9. 9.
    Moe SM (2006) Vascular calcification and renal osteodystrophy relationship in chronic kidney disease. Eur J Clin Invest 36:51–62CrossRefPubMedGoogle Scholar
  10. 10.
    Sanchez-Perales C, Vazquez Ruiz de Castroviejo E, Garcia-Cortes MJ, Biechy Mdel M, Gil-Cunquero JM, Borrego-Hinojosa J et al (2015) Valvular calcifications at the start of dialysis predict the onset of cardiovascular events in the course of follow-up. Nefrologia 35(2):157–163. doi: 10.1016/j.nefro.2015.05.017 CrossRefPubMedGoogle Scholar
  11. 11.
    Rebic D, Rasic C (2015) Valvular calcification and left ventricular modifying in peritoneal dialysis patients. Renal Fail 19:1–7Google Scholar
  12. 12.
    Wilkieson TJ (2015) Coronary artery calcification, cardiovascular events, and death: a prospective cohort study of incident patients on hemodialysis. Can J Kidney Health Dis 2:29. doi: 10.1186/s40697-40015-40065-40696 (eCollection 42015) CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Arenas MD, Alvarez-Ude F, Gil MT et al (2007) Implementation of ‘K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease’ after the introduction of cinacalcet in a population of patients on chronic haemodialysis. Nephrol Dial Transpl 22(6):1639–1644CrossRefGoogle Scholar
  14. 14.
    Wetmore JB, Quarles LD (2009) Calcimimetics or vitamin D analogs for suppressing parathyroid hormone in end-stage renal disease: time for a paradigm shift? Nat Clin Pract Nephrol 5(1):24–33CrossRefPubMedGoogle Scholar
  15. 15.
    Cunningham J, Locatelli F, Rodriguez M (2011) Secondary hyperparathyroidism: pathogenesis, disease progression, and therapeutic options. Clin J Am Soc Nephrol 6(4):913–921CrossRefPubMedGoogle Scholar
  16. 16.
    Pitt SC, Sippel RS, Chen H (2009) Secondary and tertiary hyperparathyroidism, state of the art surgical management. Surg Clin N Am 89(5):1227–1239CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Cernaro V, Santoro D, Lacquaniti A et al (2016) Phosphate binders for the treatment of chronic kidney disease: role of iron oxyhydroxide. Int J Nephrol Renovasc Dis 9:11–19CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Jamal et al (2013) Effect of calcium-based versus non-calcium-based phosphate binders on mortality in patients with chronic kidney disease: an updated systematic review and meta-analysis. Lancet 382(9900):1268–1277. doi: 10.1016/S0140-6736(13)60897 CrossRefPubMedGoogle Scholar
  19. 19.
    Zhai CJ et al (2015) Efficacy and safety of lanthanum carbonate versus calcium-based phosphate binders in patients with chronic kidney disease: a systematic review and meta-analysis. Int Urol Nephrol 47(3):527–535. doi: 10.1007/s11255-014-0876-x CrossRefPubMedGoogle Scholar
  20. 20.
    Patel L, Bernard M (2015) Sevelamer versus calcium-based binders for treatment of hyperphosphatemia in CKD: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol 14:06800615Google Scholar
  21. 21.
    Meyer C, Cameron K, Battistella M (2012) New agent to treat elevated phosphate levels: magnesium carbonate/calcium carbonate tablets. CANNT J J ACITN 22(4):33–35 quiz 36-37 Google Scholar
  22. 22.
    Field B, Booth A, Ilott I, Gerrish K (2014) Using the knowledge to action framework in practice: a citation analysis and systematic review. Implement Sci: IS 9:172CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Vlayen J, Aertgeerts B, Hannes K, Sermeus W, Ramaekers D (2005) A systematic review of appraisal tools for clinical practice guidelines: multiple similarities and one common deficit. Int J Qual Health Care 17(3):235–242. doi: 10.1093/intqhc/mzi027 CrossRefPubMedGoogle Scholar
  24. 24.
    AGREE II (2010) Advancing guideline development, reporting, and evaluation in health care. Prev Med 51(5):421–424. doi: 10.1016/j.ypmed.2010.08.005 CrossRefGoogle Scholar
  25. 25.
    Cluzeau FA, Littlejohns P, Grimshaw JM, Feder G, Moran SE (1999) Development and application of a generic methodology to asess the quality of clinical guidelines. Int J Qual Health Care 11:21–28CrossRefPubMedGoogle Scholar
  26. 26.
    Yan J, Min J, Zhou B (2013) Diagnosis of pheochromocytoma: a clinical practice guideline appraisal using AGREE II instrument. J Eval Clin Pract 19(4):626–632CrossRefPubMedGoogle Scholar
  27. 27.
    Barriocanal AM, Lopez A, Monreal M, Montane E (2016) Quality assessment of peripheral artery disease clinical guidelines. J Vasc Surg 63(4):1091–1098CrossRefPubMedGoogle Scholar
  28. 28.
    Manns BJ, Hodsman A, Zimmerman DL et al (2010) Canadian society of nephrology commentary on the 2009 KDIGO clinical practice guideline for the diagnosis, evaluation, and treatment of CKD-mineral and bone disorder (CKD-MBD). Am J Kidney Dis 55(5):800–812CrossRefPubMedGoogle Scholar
  29. 29.
    National Kideny Foudation (2003) K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis 42(4 Suppl 3):S1–201Google Scholar
  30. 30.
    Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group (2009) KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int. doi: 10.1038/ki.2009.188 Google Scholar
  31. 31.
    Centre for Clinical Practice at N (2013) National Institute for Health and Clinical Excellence: Guidance. Hyperphosphataemia in chronic kidney disease: management of hyperphosphataemia in patients with stage 4 or 5 chronic kidney disease. National Institute for Health and Clinical Excellence (UK)Copyright (c) National Institute for Health and Clinical Excellence, ManchesterGoogle Scholar
  32. 32.
    (2014) Hyperphosphataemia in chronic kidney disease evidence update December 2014. NICE guidelinesGoogle Scholar
  33. 33.
    Chadban S, Chan M, Fry K et al (2010) The CARI guidelines. Nutritional interventions for the prevention of bone disease in kidney transplant recipients. Nephrology (Carlton, Vic) 15(Suppl 1):S43–S47CrossRefGoogle Scholar
  34. 34.
    Elder G, Faull R, Branley P, Hawley C (2006) The CARI guidelines. Management of bone disease, calcium, phosphate and parathyroid hormone. Nephrology (Carlton, Vic) 11(Suppl 1):S230–S261CrossRefGoogle Scholar
  35. 35.
    Hawley C, Elder G (2006) The CARI guidelines. Biochemical targets. Nephrology (Carlton, Vic) 11(Suppl 1):S198–S216Google Scholar
  36. 36.
    Section IV. bone disease (2002) Nephrology Dialysis Transplantation, vol 17, pp 43–48.
  37. 37.
    Stedon S, Sharples E (2015) Clinical practice guideline CKD-mineral and bone disorders (CKD-MBD).
  38. 38.
    Fukagawa M, Yokoyama K, Koiwa F et al (2013) Clinical practice guideline for the management of chronic kidney disease-mineral and bone disorder. Ther Apheresis Dial 17(3):247–288CrossRefGoogle Scholar
  39. 39.
    Jindal K, Chan CT, Deziel C et al (2006) Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. J Am Soc Nephrol: JASN 17(3 Suppl 1):S1–27PubMedGoogle Scholar
  40. 40.
    Levin A, Hemmelgarn B, Culleton B et al (2008) Guidelines for the management of chronic kidney disease. CMAJ. Can Med Assoc J 179(11):1154–1162CrossRefGoogle Scholar
  41. 41.
    Torregrosa JV, Cannata Andia J, Bover J et al (2008) SEN guidelines. Recommendations of the Spanish Society of Nephrology for managing bone-mineral metabolic alterations in chronic renal disease patients. Nefrologia 28(Suppl 1):1–22PubMedGoogle Scholar
  42. 42.
    Prados-Garrido MD, Bover J, Teresa González-Álvarez M (2011) Clinical practice guideline for chronic kidney disease-mineral and bone disease (2010 version). Dialisis Transplante 32(3):108–118Google Scholar
  43. 43.
    Mazzaferro S, Cozzolino M, Marangella M, Strippoli GF, Messa P (2007) Calcimimetics, phosphate binders, vitamin D and its analogues for treating secondary hyperparathyroidism in chronic kidney disease: guideline from the Italian Society of Nephrology. Giornale italiano di nefrologia 24(Suppl 37):S107–S124PubMedGoogle Scholar
  44. 44.
    Carvalho AB, Gueiros AP, Gueiros JE et al (2012) Guidelines on bone mineral disorder in chronic kidney disease–addendum chapter 2. Jornal brasileiro de nefrologia 34(2):199–205CrossRefPubMedGoogle Scholar
  45. 45.
    Anonymous (2009) Guidelines of the Ministry of Health of the Slovak Republic for the treatment of bone and mineral metabolism disorders in patients with chronic kidney disease. Aktuality v Nefrologii 15(3):121–127Google Scholar
  46. 46.
    Guyatt GH, Oxman AD, Santesso N et al (2013) GRADE guidelines: 12. Preparing summary of findings tables-binary outcomes. J Clin Epidemiol 66(2):158–172CrossRefPubMedGoogle Scholar
  47. 47.
    Guyatt GH, Oxman AD, Vist GE et al (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ (Clinical research ed.) 336(7650):924–926CrossRefGoogle Scholar
  48. 48.
    Zarnke KB, Campbell NR, McAlister FA, Levine M (2000) A novel process for updating recommendations for managing hypertension: rationale and methods. Can J Cardiol 16(9):1094–1102PubMedGoogle Scholar
  49. 49.
    Djulbegovic B, Guyatt GH (2014) Evidence-based practice is not synonymous with delivery of uniform health care. JAMA 312(13):1293–1294CrossRefPubMedGoogle Scholar
  50. 50.
    Smith CA, Toupin-April K, Jutai JW et al (2015) A systematic critical appraisal of clinical practice guidelines in juvenile idiopathic arthritis using the appraisal of guidelines for research and evaluation II (AGREE II) instrument. PLoS One 10(9):e0137180CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Brosseau L, Rahman P, Poitras S et al (2014) A systematic critical appraisal of non-pharmacological management of rheumatoid arthritis with appraisal of guidelines for research and evaluation II. PLoS One 9(5):e95369CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Brosseau L, Rahman P, Toupin-April K et al (2014) A systematic critical appraisal for non-pharmacological management of osteoarthritis using the appraisal of guidelines research and evaluation II instrument. PLoS One 9(1):e82986CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Hazlewood GS, Akhavan P, Schieir O et al (2014) Adding a “GRADE” to the quality appraisal of rheumatoid arthritis guidelines identifies limitations beyond AGREE-II. J Clin Epidemiol 67(11):1274–1285CrossRefPubMedGoogle Scholar
  54. 54.
    Vlayen J, Aertgeerts B, Hannes K, Sermeus W, Ramaekers D (2005) A systematic review of appraisal tools for clinical practice guidelines: multiple similarities and one common deficit. Int J Qual Health Care 17(3):235–242CrossRefPubMedGoogle Scholar
  55. 55.
    Watine J, Friedberg B, Nagy E et al (2006) Conflict between guideline methodologic quality and recommendation validity: a potential problem for practitioners. Clin Chem 52(1):65–72CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2016

Authors and Affiliations

  • Nigar Sekercioglu
    • 1
    Email author
  • Reem Al-Khalifah
    • 9
  • Joycelyne Efua Ewusie
    • 1
  • Rosilene M. Elias
    • 10
  • Lehana Thabane
    • 1
    • 5
    • 6
    • 7
    • 8
    • 9
  • Jason W. Busse
    • 1
    • 3
    • 4
  • Noori Akhtar-Danesh
    • 1
  • Alfonso Iorio
    • 1
    • 2
  • Tetsuya Isayama
    • 1
  • Juan Pablo Díaz Martínez
    • 1
  • Ivan D. Florez
    • 1
    • 11
  • Gordon H. Guyatt
    • 1
    • 2
  1. 1.Department of Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonCanada
  2. 2.Department of MedicineMcMaster UniversityHamiltonCanada
  3. 3.The Michael G. DeGroote Institute for Pain Research and CareMcMaster UniversityHamiltonCanada
  4. 4.Department of AnesthesiaMcMaster UniversityHamiltonCanada
  5. 5.Department of Pediatrics and AnesthesiaMcMaster UniversityHamiltonCanada
  6. 6.Centre for Evaluation of MedicineSt Joseph’s Healthcare—HamiltonHamiltonCanada
  7. 7.Biostatistics Unit, Father Sean O’Sullivan Research CentreSt Joseph’s HealthcareHamiltonCanada
  8. 8.Population Health Research InstituteHamilton Health SciencesHamiltonCanada
  9. 9.Division of Pediatric EndocrinologyKing Saud UniversityRiyadhSaudi Arabia
  10. 10.Nephrology DepartmentUniversity of Sao Paulo School of MedicineSão PauloBrazil
  11. 11.Department of PediatricsUniversity of AntioquiaMedellinColombia

Personalised recommendations