Bibliographic Source(s)

• Hawley C Elder G. Calcium. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Oct. 7 p. [14 references]



• Hawley C. Calcium. Nephrology 2006 Apr;11(S1):S198-200.

Guideline Status

This is the current release of the guideline.

Guideline Category

Management
Treatment

Intended Users

Physicians

Guideline Objective(s)

To explore whether there is an association between serum calcium and all-cause mortality and cardiovascular mortality in particular while giving consideration to the well-established link between hypocalcaemia and worsening hyperparathyroidism

Target Population

Adults and children with chronic kidney disease

Interventions and Practices Considered

Maintenance of serum calcium level within the normal range (considered but not recommended)

Major Outcomes Considered

• Cardiovascular mortality
• All-cause mortality
• Metabolic bone disease

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

Databases searched: MeSH terms and text words for kidney dialysis were combined with MeSH terms and text words for serum calcium. This search was carried out in Medline (1966 to April Week 3 2005). The Cochrane Renal Group Trials Register was also searched for calcium trials not indexed in Medline.

Date of searches: 3 March 2004. A further Medline search was carried out for the period 1 Feb 2004 to 30 Apr 2005.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized cohort studies case-control studies interrupted time series with a control group; comparative studies with historical control two or more single arm studies interrupted time series without a parallel control group

Level IV: Evidence obtained from case series either post-test or pretest/post-test

Methods Used to Analyze the Evidence

Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Comparison with Guidelines from Other Groups
Peer Review

Description of Method of Guideline Validation

Recommendations of Others. Recommendations regarding serum calcium levels in patients with chronic kidney disease from the following groups were discussed: Kidney Disease Outcomes Quality Initiative British Renal Association Canadian Society of Nephrology European Best Practice Guidelines and International Guidelines.

Major Recommendations

Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.

Guidelines

No recommendations possible based on Level I or II evidence

Suggestions for Clinical Care

(Suggestions are based on Level III and IV evidence)

• In Stage 5 kidney disease predialysis albumin-corrected serum calcium should be kept within the normal laboratory reference range preferably towards the lower end (2.1 to 2.4 mmol/L) provided that keeping serum calcium at this level does not worsen hyperparathyroidism. (Opinion)
• In Stage 3 and 4 kidney disease serum calcium should be kept within the normal laboratory reference range. (Opinion)
• A predialysis blood sample should be used. (Level III evidence)

Definitions:

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized cohort studies case-control studies interrupted time series with a control group; comparative studies with historical control two or more single arm studies interrupted time series without a parallel control group

Level IV: Evidence obtained from case series either post-test or pretest/post-test

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Potential Benefits

Appropriate management of serum calcium levels in patients with chronic kidney disease

Potential Harms

Keeping serum calcium at the lower end (2.1 to 2.4 mmol/L) of normal may worsen hyperparathyroidism.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Bibliographic Source(s)

• Hawley C Elder G. Calcium. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Oct. 7 p. [14 references]



• Hawley C. Calcium. Nephrology 2006 Apr;11(S1):S198-200.

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Industry-sponsored funding administered through Kidney Health Australia

Guideline Committee

Not stated

Composition of Group that Authored the Guideline

Authors: Carmel Hawley and Grahame Elder

Financial Disclosures/Conflicts of Interest

All guideline writers are required to fill out a declaration of conflict of interest.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Caring for Australasians with Renal Impairment Web site.

Print copies: Available from Caring for Australasians with Renal Impairment Locked Bag 4001 Centre for Kidney Research Westmead NSW Australia 2145

Availability of Companion Documents

The following is available:

• The CARI guidelines. A guide for writers. Caring for Australasians with Renal Impairment. 2006 May. 6 p.

Electronic copies: Available from the Caring for Australasians with Renal Impairment (CARI) Web site.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on June 5 2008. The information was verified by the guideline developer on June 11 2008.

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This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.

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