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Critical Appraisal of International Clinical Practice Guidelines in Kidney Transplantation Using the Appraisal of Guidelines for Research and Education II Tool

A Systematic Review

O'Donoghue, Katriona Jane Marie1; Reed, Rhiannon D.2; Knight, Simon R., MChir1,3; O'Callaghan, John M.1,3; Ayaz-Shah, Anam A.1; Hassan, Sevda4; Weissenbacher, Annemarie, MD3; Morris, Peter J., FRS1,3; Pengel, Liset H.M., PhD1,3

doi: 10.1097/TP.0000000000002255

Background Although clinical practice guidelines (CPGs) are used for the development of local protocols in kidney transplantation (Ktx), the quality of their methodology is variable. This systematic review aimed to critically appraise international CPGs in all aspects of Ktx using the Appraisal of Guidelines for Research and Evaluation II tool.

Methods Clinical Practice Guidelines in Ktx and donation published between 2010 and 2017 were identified from MEDLINE, Embase, National Guideline Clearinghouse, National Health Service and National Institute for Health and Care Excellence Evidence Searches, and the websites of transplant societies. Using Appraisal of Guidelines for Research and Evaluation II, 3 appraisers assessed the quality of CPGs. Interrater reliability was measured using the intraclass correlation coefficient (ICC).

Results Searches identified 3168 records, and 115 CPGs were included. The highest scoring Appraisal of Guidelines for Research and Evaluation II domain was “scope and purpose” (80%; range, 30%-100%), followed by “clarity of presentation” (77%; range, 43%-98%), “editorial independence” (52%; range, 0%-94%), “rigor of development” (47%; range 6%-97%) and “stakeholder involvement” (41%; range, 11%-85%). The poorest scoring domain was “applicability” (31%; range, 3%-74%). Most CPGs were recommended for future use either with (63%) or without (18%) modifications. A small number (14%) were not recommended for future use or reviewers (5%) did not agree on recommending the CPG. The overall mean CPG quality score was 4 of 7 (range, 2-7). The mean ICC of 0.74 indicated substantial agreement between reviewers.

Conclusions The quality of international CPGs in Ktx was variable, and most CPGs lacked key aspects of methodological robustness and transparency. Improvements in methodology, patient involvement, and strategies for implementation are required.

Clinical Practice Guidelines in kidney transplantation are appraised in this systematic review looking at quality and interrater variability. Overall, most CPGs lacked key aspects of methodological robustness and transparency, which leaves room for significant improvement.

1 Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, United Kingdom.

2 University of Alabama at Birmingham, Comprehensive Transplant Institute, Birmingham, AL.

3 Nuffield Department of Surgical Sciences, University of Oxford John Radcliffe Hospital, Headington, Oxford, United Kingdom.

4 West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.

Received 19 February 2018. Revision received 29 March 2018.

Accepted 18 April 2018.

Correspondence: Katriona J.M. O'Donoghue, Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons, 35-43 Lincoln's Inn Fields, London WC2A 3PE, United Kingdom. (

The authors declare no funding or conflicts of interest.

Systematic review registration: PROSPERO ID: CRD42015027356.

K.O., R.R., S.K., J.O., P.M., and L.P. were involved in the concept and design of the systematic review. K.O. and L.P. designed the search strategy. K.O. and R.R. screened search results for relevant full texts, and these were checked by L.P., K.O., and R.R. performed the data extraction. All authors were involved in the critical appraisal of guidelines with AGREE II. K.O. wrote the initial drafts of the article and these were revised by L.P. All authors critically revised the final draft of the article. K.O. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. K.O. is the guarantor.

All authors have completed the ICMJE uniform disclosure form at

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