The Canadian Society of Nephrology Methods for Developing and Adapting Clinical Practice Guidelines: An Update

Abstract

Purpose of the review:

In this article, we provide an update on the Canadian Society of Nephrology’s (CSN) process of identifying candidate topics and subsequent development of guidelines and commentaries using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT methodology. We revise the process of adapting existing guidelines with the inclusion of Kidney Disease Improving Global Outcomes (KDIGO) practice points. We also describe challenges of implementing guidelines and suggest solutions to address this with description of the CSN approach to disseminating and implementing guidelines.

Sources of information:

The update reflects internal CSN documentation, stakeholder consultation for topic prioritization, and integration of methodological guidance from GRADE-ADOLOPMENT and international sources such as KDIGO.

Methods:

We reviewed and synthesized the CSN’s current guideline-development process, which includes a detailed examination of internal documentation, meeting summaries, and publicly available methodological frameworks with specific focus on the application of the GRADE-ADOLOPMENT approach. We analyzed how recommendations and practice points from KDIGO are assessed for relevance, updated based on Canadian context, and integrated into the final commentary using GRADE Evidence-to-Decision (EtD) frameworks. We also examined how conflict of interest is managed, how working groups are structured, and how recommendations are prioritized. In addition, we explored the CSN’s evolving strategies for dissemination and implementation, including stakeholder engagement, survey feedback, and use of knowledge-translation tools.

Key findings:

The CSN follows a transparent and rigorous process in guideline and commentary development. This comprehensive process considers the best-available evidence, balancing desirable and undesirable effects and patients’ values, perspectives, and implications for the Canadian health care system including resources, equity, acceptability, and feasibility to maximize guideline implementation and advance the health of Canadians.

Limitations:

The CSN updated methods reflect the current process and may not be generalizable to other guideline organizations. The impact of CSN commentaries on clinical practice, decision-making, and policy uptake has not been formally evaluated, limiting our understanding of their contribution to health system improvement and patient outcomes.

Implications:

This review updates the CSN’s processes for commentary working groups to identify relevant international guidelines, establish the level of agreement on included recommendations, incorporate perspectives of people with lived experience, and adjust the final product to the Canadian healthcare system before dissemination.

Introduction

Clinical practice guidelines (CPGs) provide organized recommendations that are evidence-based and meant to guide the diagnosis and management of medical conditions. ¹ They summarize the current knowledge to assist healthcare professionals and inform shared decision-making that ultimately ensures patients receive appropriate care. Two decades ago, there was no universally agreed on process on how CPGs were produced. Multiple frameworks have been developed to provide a systematic approach to guideline development like the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology ² which has been endorsed by multiple guideline-producing organizations around the world. However, it is now recognized that implementation of guideline recommendations has unique challenges at the local setting and could be limited by multiple challenges mostly related to the unique needs and resources of the local healthcare system. ³ This has led to the recent refinement of the GRADE-ADOLOPMENT methodology, designed to facilitate the contextualization of recommendations to a local setting or specific circumstances within a short timeframe or with limited resources. ⁴

The Canadian Society of Nephrology (CSN) is a body of professionals specializing in the care of people with kidney disease that is committed to supporting kidney disease healthcare providers to advance the care of Canadians at risk for, or with kidney disease through setting standards for kidney care and facilitating research that advances the science of kidney health and disease. ⁵ The CPG committee (CPGC) was established to improve the delivery of healthcare to Canadians living with kidney disease through the development of recommendations for CSN members, ⁶ whether in the form of de novo guidelines or commentaries on other societies’ guidelines such as those from the Kidney Disease Improving Global Outcomes (KDIGO) group. The CSN CPGC has developed multiple guidelines and commentaries following a rigorous process to ensure that recommendations are evidence-based and inform clinical care and is tailored to the Canadian health care system.

In 2014, the CSN CPGC reported on their standards for developing de novo guidelines and commentaries of existing guidelines. ⁷ Herein, we present updated methods that the CPGC follows, which now incorporate broad stakeholder input to prioritize guideline topics, in addition to a more detailed process for handling formal recommendations versus practice points. Practice points are a new form of guidance produced in addition to recommendations and were first used in the 2021 KDIGO glomerulonephritis (GN) guidelines. They represent expert consensus statements to provide guidance to clinicians when a systematic review was not conducted or where there is insufficient evidence to warrant a recommendation. The practice points could be formatted as tables, figures, or algorithms and do not include an explicit discussion about benefits, harms, patient values, and other considerations including resources. ⁸ On the other hand, formal graded recommendations have structure format, are supported by evidence based on systematic reviews, and include an explicit discussion about benefits, harms, patient values, and other considerations.

In this article, we provide an update on the previously published CSN process of CPG development. While we briefly summarize the de novo CPG development using the GRADE-ADOLOPMENT approach, the main focus of this updated review is to describe the methods for creating commentaries on existing guidelines. Commentaries play a critical role in rapidly translating global recommendations into the Canadian context, accounting for differences in healthcare system and resources. This update is particularly timely given recent changes in the KDIGO guideline format, including the formal addition of practice points. Further, the CPGC has active commentary working groups for recently published KDIGO guidelines, including those on anemia, GN, and autosomal dominant polycystic kidney disease (ADPKD). These developments prompted refinement of the CSN commentary development process to maintain methodological rigor, relevance, and clinical utility for Canadian practice.

Review

Prioritizing Topics for Guideline Development

The CSN CPGC recognized that many of the initiatives within the committee and for other guideline developing groups have been historically initiated based on priorities of individuals within the clinical and scientific communities. In the past, this process did not include a systematic process of identifying priorities of people with kidney disease or their care givers. Therefore, in 2022, the CSN CPGC identified this as an important area for development and began a structured process of determining which de novo guideline and commentary topics were priorities to diverse stakeholders in the Canadian kidney community, including patients, caregivers, clinicians, and researchers. ⁹

The prioritization process began with a comprehensive literature review to identify existing gaps, emerging challenges, and underdeveloped areas in nephrology guidelines, which formed a preliminary list of topics. ⁹ This list was then used in a survey distributed to multidisciplinary stakeholders to suggest additional topics and rate their importance based on criteria such as clinical relevance, evidence gaps, feasibility, and potential impact on patient care. Eighty-five participants (including 18 people with lived experience) from diverse backgrounds and locations across Canada responded to the survey. Overall, 100 topics were reviewed in a multi-phase Delphi survey process, and 12 topics were prioritized as being important (8 were de novo guidelines and 4 commentaries on existing international kidney guidelines). ⁹ The CSN CPGC has already incorporated the findings from this survey into its process of prioritization to ensure its work is informed by the priorities of Canadians with kidney disease. The CSN CPGC has established a working group to develop a commentary on the 2021 and 2024 KDIGO Glomerular Diseases guideline, which was identified as a priority in the survey and is nearing completion at this time (Table 1). These priorities will continue to be updated and will serve as the CSN CPGC compass in the years that follow.

Table 1.

Summary of the CSN CPGC Active Projects and Prioritized Topics for Novel Guideline or Commentary.

Box 1: List of current CSN CPGC active projects
Conservative kidney management de novo guideline
PD catheter insertion by nephrologists de novo guideline
Commentary on 2021 KDIGO guideline on Glomerular Diseases
Commentary on 2025 KDIGO guideline on Autosomal Dominant Polycystic Kidney Disease
Commentary on upcoming 2025 KDIGO guideline on Anemia management in people with kidney disease
Box 2: List of CSN CPG prioritized topics for novel guideline or commentary a
Novel guidelines	Commentary on international guideline
Kidney protection and slowing progression with novel therapeutics	KDIGO 2021/2024 Clinical Practice Guideline for the Management of Glomerular Disease
Patient oriented/education guidelines on diet and exercise in CKD/kidney failure	KDIGO 2020 Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation
Provision of mental health care for patient and caregivers with CKD and kidney failure	KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease
Management of symptoms of early and late CKDGuidelines for primary care settingSelf-management for dialysis recipientsAnticoagulation in advanced CKD and kidney failure	KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in CKD
Indigenous health and kidney disease

Note. CSN = Canadian Society of Nephrology; CPGC = Clinical Practice Guidelines Committee; PD = peritoneal dialysis; KDIGO = Kidney Disease: Improving Global Outcomes; CKD = chronic kidney disease.

a

Box 2 is adopted with permission from Harrison et al. ⁹

The CSN Current Process for Developing Clinical Practice Guidelines

The CSN CPGC follows the same process of developing de novo guidelines that has been previously reported. ⁷ In summary, the process begins with identifying and prioritizing guideline topics through surveys and consultations with stakeholders, including nephrologists, allied health professionals, and patients, to ensure alignment with the needs of the nephrology community. A multidisciplinary working group is then established, comprising experts in clinical nephrology, guideline development, and other relevant fields, as well as representatives from diverse practice settings and geographic regions across Canada. Conflicts of interest (COI) are managed according to established principles adapted from World Health Organization (WHO) guidance; ¹⁰ further details are provided in the section on commentary development below. This group collaborates to define the scope of the guideline, focusing on specific clinical questions formulated using the PICO (patient, intervention, comparison, outcome) framework, ensuring a targeted and evidence-driven approach.

A systematic literature search is conducted to identify relevant evidence, which is critically appraised and summarized using the GRADE methodology. This evidence synthesis supports the development of recommendations using the GRADE Evidence-to-Decisions (EtD) framework. ¹¹ The EtD provides a structured approach to developing recommendations while considering balance of benefits and harms, quality of evidence, and patient values and considerations about cost, feasibility, acceptability, and equity. This approach includes the following steps: formulating relevant questions, assessing the evidence across multiple criteria (e.g., benefits, harms, resource use, equity, feasibility, and acceptability), and drawing actionable conclusions. Following this clear process leads to developing recommendations that are either strong or conditional in strength. Guideline drafts undergo external peer review by the CSN CPGC members to ensure accuracy, relevance, and methodological rigor. The final guidelines are disseminated through peer-reviewed publications, presentations at conferences, and posting on the CSN website, with strategies for effective implementation in clinical practice. This approach enables the CSN CPGC to account for local health system constraints, cultural factors, and patient preferences, ensuring the guidelines are both evidence-based and applicable to Canadian settings. Figure 1 summarizes this process of creating de novo guidelines.

Figure 1.

(A) Summary of the Canadian Society of Nephrology (CSN) process for developing commentaries. (B) Summary of the CSN process for developing de novo guidelines.

The CSN Updated Process for Adapting and Commenting on Existing Clinical Practice Guidelines

There are multiple North American and international organizations that develop both nephrology guidelines and guidelines on topics of relevance to the nephrology community such as those focused on management of hypertension and diabetes. As an example, KDIGO is a global organization with a goal to develop CPGs on topics related to the care of individuals with kidney disease. ¹² Given the large scope and resources required by KDIGO to complete such guidelines, the CSN CPGC has formalized collaborations with KDIGO to enable timely commentary development; these commentaries are immediately relevant to the Canadian nephrology community and avoid duplication of guideline efforts.

Commentaries published by CSN must maintain scientific rigor by using a standardized process, utilizing the GRADE-ADOLOPMENT approach as a framework to guide the process. Given the recent inclusion of practice points into KDIGO guidelines, ⁸ the CSN has updated the standardized steps for developing commentaries of existing CPGs (Figure 1). Of note, these suggested steps may be tailored as needed by a guideline working group in collaboration with the CSN CPGC.

First, a working group is established for the commentary, which initially consists of a Chair and co-Chair, appointed by the CSN CPGC. A multidisciplinary working group is then formed with invitations to CSN members or those from the Canadian kidney community with known expertise and experience in the topic. The composition varies depending on the guideline, but in general includes nephrologists (adult and pediatric) with clinical and content expertise, relevant physician specialty groups (such as endocrinology, primary care etc.), people with lived experience of kidney disease (including patients, family members, and informal caregivers), and members of the allied health community (pharmacists, nursing, dieticians etc.), with consideration for geographical representation across Canada and other equity factors such as age, gender, and career stage.

COI should be declared and managed in accordance with principles adapted from the GRADE-ADOLOPMENT methodology ¹³ and the Saudi Arabian Guideline Development Handbook, ¹⁴ which aligns with the WHO approach. ¹⁰ The CSN has an official COI policy which was updated in 2024, which is followed by all CSN CPGC and working group members. ¹⁵ All working group members are required to disclose financial, personal, or intellectual conflicts prior to participation. Disclosures are reviewed by the CSN-CPGC leadership to ensure balance in panel composition per the CSN COI. To maintain objectivity, team members with significant COI related to specific sections will be asked to step back from contributing to those parts of the commentary or participating in related discussions. Perceived COI, where a situation might appear to involve a COI as judged by external observers, are addressed on a case-by-case basis. Working group members are expected to update their disclosures as needed throughout the process, with any new or evolving conflicts reviewed and managed using the same approach. Declarations of interest will be included in the final published guideline. This process aims to uphold transparency, minimize bias, and maintain the integrity of the commentary development. The working group systematically reviews all recommendations and practice points, identifying those that require inclusion in the commentary. Examples of recommendations or practice points that are relevant for interpretation and application may include those with: (1) high yield for clinical practice, (2) consideration of resource and health care delivery constraints specific to Canada (frequently excluded from guideline development), and (3) those with potential for targeted knowledge translation activities relevant to the local, regional, and national context. In addition, recommendations may be identified for discussion by the working group if there is a need to review the evidence on which they are based. Practice points often include tables or figures of high clinical utility and should be carefully considered for inclusion in the commentary. Recommendations or practice points that have implications for Canadian kidney healthcare can be additionally discussed and included in the commentary.

The systematic review of recommendations and practice points by working group members is handled as follows:

• 1. Recommendations: Prior to the first working group meeting, each member completes a survey which determines the level of consensus for each recommendation, or need for discussion.

• For each item reviewed, working group members will indicate whether the item requires discussion regarding the supporting evidence, requires discussion for Canadian implications, does not require discussion (i.e. agree with recommendation or practice point), or they may abstain from responding. An accompanying free text box for each question is also provided to input specific comments related to a Canadian health care implication, related to the evidence base, or any other relevant discussion points.

• Consensus thresholds can be determined at the discretion of the working group but should be identified in advance of survey administration. For example, consensus and agreement (and no need for discussion) can be defined as >80% (no need for discussion/total responses), and disagreement as < 80% (need for discussion based on recommendation evidence/total responses). While the 2014 CSN methods ⁷ described achieving consensus through structured discussions and iterative group review, it did not define a specific numerical threshold for consensus, which was additionally missing in previously published CSN commentaries. In this updated approach, we formalize the process by introducing clear consensus thresholds (commonly >80%) during the pre-meeting survey phase. This threshold is based on a systematic review of Delphi studies by Diamond et al., ¹⁶ which found that the most common approach to defining consensus was based on percent agreement, with a median reported threshold of 75% (range: 50%–97%). As mentioned, these thresholds can be tailored based on working group needs and the size of the guideline while adhering to usual thresholds used in Delphi studies ¹⁶ and should be defined a priori to ensure the scope of the commentary is feasible. “Abstain” answers should be excluded from the denominator in these calculations. Items that are flagged as having important Canadian contextual implications will be discussed regardless of the proportion of respondents that deemed discussion necessary.

• Using the predetermined consensus thresholds, recommendations where there was agreement that no discussion was needed, or where no potential implications for Canadian health care were identified, will not be included in the commentary or discussed further at the working group meeting. Otherwise, recommendations will be included for further discussion at the working group meeting.

• 2. Practice points: Working group members are assigned specific guideline chapters in advance of the first meeting. Each member is required to review their assigned chapters’ practice points, with consideration given to the criteria outlined above regarding points requiring further exploration. These practice points are presented and discussed at working group meetings. Depending on the number of practice points included in the guideline, working groups may determine a priori whether they would like to assess each point with the same process as for guideline recommendations.

Responses from the survey, including free text comments, are collated and disseminated in advance of the first working group meeting and are used to frame meeting discussions. The focus of discussion at the working group meetings is to determine the recommendations and practice points to be included in the commentary. The commentary also may address and incorporate pertinent evidence available since publication of the cited guidelines. While the group does not necessarily perform or conduct systematic reviews to inform the commentary, any new studies since the publication of the guideline are incorporated into the discussion.

At the end of the discussion, working group members can once again be taken through an exercise to identify whether there is consensus for the recommendations and practice points to be included in the commentary. This step is at the discretion of the working group. Once the discussion is concluded, working group members utilize meeting minutes and survey results to draft their assigned chapters. A chapter template is provided to all working group members in advance. This will include explicit discussions for the included recommendations or practice points in the chapter and implications for Canadian health care. The people with lived experience in the working group will also be asked to provide their comments and perspective from a patient lens.

The CSN CPGC arranges peer review of the commentary with up to three reviewers (CSN members with peer review expertise), following which the working group undertakes revisions based on reviewer comments. As KDIGO may begin updating guidelines by individual chapters rather than full guidelines, the CSN CPGC will similarly adapt its approach by developing commentaries on specific chapters as needed. This final document will then be submitted for publication in a peer-reviewed journal. Figure 1 summarizes this process for developing commentaries.

In addition to developing commentaries on clinical practice guidelines, the CSN may also apply the GRADE-ADOLOPMENT process to adapt existing international guidelines with consideration to local variation in baseline risk of different conditions, Canadian values, costs, feasibility, acceptability, and equity considerations which may result in different recommendations.

Dissemination and Implementation of the CSN Guidelines and Commentaries

Dissemination of the CSN guidelines and commentaries can be done through a variety of approaches including publication in peer-reviewed nephrology journals, posting the full commentary or guideline on the CSN website, posting summaries with relevant links on different national platforms including Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease platform (Can-SOLVE CKD), ¹⁷ Kidney Foundation of Canada, ¹⁸ provincial kidney agency websites, patient partner organizations such as KidneyLink, ¹⁹ and Canadian Donation and Transplantation Research Program (CDTRP), ²⁰ as well as on other international nephrology guideline websites. The CPGs and commentaries can also be presented at appropriate local, national, and international forums. As a future endeavor, CSN might integrate a public review process for de novo guidelines, allowing broader feedback from stakeholders, including patients, caregivers, and clinicians, to enhance their relevance and quality. This public review process may not necessarily apply to commentaries but will strengthen transparency and engagement in guideline development.

Challenges Faced and Suggested Solutions

The GRADE-ADOLOPMENT process, ⁴ which integrates adopting, adapting, and developing recommendations based on high-quality systematic reviews, is the internationally accepted standard method for guideline development. This process helps ensure recommendations are evidence-based and can be practically implemented for real-world healthcare settings. However, the financial and time costs associated with this rigorous process are substantial as it requires multiple rounds of meetings and time dedicated to guideline and methods review by the working group members and methodologists. In addition, methodologic expertise is required in evidence synthesis and systematic review, critical appraisal of evidence and the formulation of evidence-based recommendations. To address these challenges, CSN offers GRADE methods training ²¹ to CSN CPGC and guideline panel members if wanted and has hosted workshops on GRADE in the past, fostering early collaborations with KDIGO on upcoming guidelines to enable timely CSN commentary, and engaging in formal topic prioritization work to ensure upcoming CSN resources used for new guidelines and commentaries are of value to all relevant stakeholders. Furthermore, enhancing inclusiveness, ensuring representation of minority populations, and establishing clear criteria for updating guidelines are areas that require attention. Monitoring literature reviews and identifying practice-changing evidence can guide decisions on when to update guidelines. Building on the success of the prioritization process ⁹ —whether driven by expert input, systematic sampling, or comprehensive literature review—can further ensure that updates and commentaries are both timely and relevant to stakeholders. Finally, currently, there is no formal process to track how CSN guidelines and commentaries are being implemented in practice, which we recognize as an important area for improvement in the future. KDIGO has explored this issue as was presented at the Implementation Strategies Conference, ²² which could offer helpful models for CSN to consider. This is important, as it is estimated that it can take up to 17 years for guidelines to be fully adopted into clinical practice. In fact, a survey of Canadian nephrologists showed that nearly 45% of practitioners did not follow the 2012 KDIGO GN recommendations at the time. ²³ Moving forward, the CSN might consider conducting similar surveys to better understand guideline uptake in Canada and explore ways to link adherence with patient outcomes, perhaps starting with local or provincial efforts.

Conclusion

The CSN CPGC is dedicated to advancing the field of nephrology by adopting best practices through developing de novo CPGs and writing commentaries on existing guidelines summarizing the state-of-the-art scientific evidence. This is done through a comprehensive process that follows the GRADE-ADOLOPMENT methodology for developing and adapting guidelines, respectively. In addition to assessing the quality of the available evidence, the CSN CPGC ensures that adaptation of guidelines aligns with the Canadian context. The updated processes described in this review outline how commentary working groups identify relevant international guidelines, establish the level of agreement on included recommendations, incorporate perspectives of people with lived experience, and adjust the final product to the Canadian healthcare system before dissemination. Applying this process fulfills the CSN role to advance high-quality care and research to improve outcomes for people with kidney disease.