Hierro Polimaltosado No Ionico

R ES E A R C H

Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis
Michelle J Irving, Jonathan C Craig, Martin Gallagher, Stephen McDonald, Kevan R Polkinghorne, Rowan G Walker and Simon D Roger

S

tudies examining the link between research evidence and clinical practice have consistently shown gaps between the evidence andcurrent practice. Some studies in the United States suggest that 30%–40% of patients do not receive evidence-based care, Journalin 20% of patients The Medical while of Australia ISSN: care may be not needed or potentially harm0025-729X 18 September 2006 185 6 However, ful.1 310-314 relatively little information exists ©The Medical apply evidence in clinical about how to Journal of Australia 2006www.mja.com.au practice, and data on the effect of evidencebasedResearch on knowledge uptake, procguidelines ess of care or patient outcomes is limited. In Australia and New Zealand, national guidelines for treating patients with chronic kidney disease — the Caring for Australasian s with renal i mp airm ent (CA RI) guidelines2 — were published and disseminated to nephrologists in March 2000, withdetails and updates on the CARI website (http://www.cari.org.au). They provide nephrologists, renal nurses and other health carers with an evidence base for patient management and improving outcomes. The focus of one of the CARI guidelines2 is anaemia, a common complication of chronic kidney disease. Management of iron levels in patients with chronic kidney disease involves both excluding irondeficiency in uraemic– anaemic patients, and providing adequate iron stores to allow patients to efficiently maintain target haemoglobin concentrations, especially with the concomitant use of supplementary erythropoietin proteins (epoetin). Failure to achieve adequate iron stores and availability is the major cause of epoetin resistance, which may result in increased costs to correct the anaemia.3 Inobservational studies of haemodialysis patients, it has been shown that the relative risk of death and hospitalisation increases significantly with haemoglobin levels below the target.4 In an effort to understand the impact of guidelines, our study was designed to evaluate the outcomes of a standard implementation strategy (passive dissemination of guidelines in hardcopy form and on the Internet)of the CARI guidelines using an example — iron management of dialysis patients in Australia. In assessing this strategy, we sought to identify barriers to guideline implementation5-7 using a “process of care” approach, with a view to 310

ABSTRACT
Objective: To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), usingiron management in patients having dialysis as an example. Design and setting: On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients’ iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry. Participants: Patients with chronic kidney disease who were dependent on dialysis.Main outcome measures: Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines. Results: There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%–32% of patients achieving haemoglobin targets of 110–120 g/L, 30%–68% achieving ferritin targets of 300–800 μg/L, and 65%–73%achieving transferrin saturation targets of 20%–50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer...