Australian and New Zealand Society of Nephrology
Evolve Top-5 Recommendations on low-value practices

The Australian and New Zealand Society of Nephrology is a not-for profit organisation representing the interests of health professionals committed to the prevention and treatment of kidney disease.

Through the ANZSN, members support a range of research, education and clinical care initiatives to promote evidenced based practice and quality outcomes for patients in Australia, New Zealand and our region.

Download the Australian and New Zealand Society of Nephrology Evolve Top-5 Recommendations

1

Do not give multiple daily doses of aminoglycoside antibiotics to patients with normal and stable kidney function as the risk of toxicity is less with a single dose

Rationale

Aminoglycosides are powerful and widely used antibiotics. Acute kidney injury (AKI) is a well-known complication of aminoglycosides. Because efficacy of these antibiotics is concentration-dependent rather than time-dependent and their renal toxicity depends more on duration of therapeutic levels than on peak levels, frequent doses should be avoided. For instance, once- and three-times daily aminoglycoside antibiotics appear to be equally effective in the treatment of pulmonary exacerbations of cystic fibrosis and to be less toxic to children’s kidneys. Similarly, a twice daily gentamicin dosing regimen has been proven neither less nephrotoxic nor more efficient than a once daily regimen in the treatment of infective endocarditis.The use of extended-interval (once daily) dosing for aminoglycosides is also effective and safe for immunocompromised patients with febrile neutropenia.

Evidence

Buchholtz K; Larsen CT; Schaadt B; Hassager C; Bruun NE Once versus twice daily gentamicin dosing for infective endocarditis: a randomized clinical trial. Cardiology. 2011; 119(2):65-71

Levison ME, Levison JH. Pharmacokinetics and pharmacodynamics of antibacterial agents. Infect Dis Clin North Am. 2009;23(4):791–vii

Smyth AR, Bhatt J, Nevitt SJ. Once-daily versus multiple-daily dosing with intravenous aminoglycosides for cystic fibrosis. Cochrane Database Syst Rev. 2017;3(3):CD002009. Published 2017 Mar 27

Stabler SN, Ensom MH. Extended-interval aminoglycoside therapy for adult patients with febrile neutropenia: a systematic review. Can J Hosp Pharm. 2011 May;64(3):182-91
2

Do not use oral acetylcysteine before giving radiocontrast to patients at increased risk for contrast-induced acute kidney injury

Rationale

Routine use of acetylcysteine for patients undergoing angiography is not recommended.The largest randomised trial to date of 5,177 patients at high risk of renal complications who underwent angiography showed there was no benefit of oral acetylcysteine over placebo for the prevention of contrast-induced acute kidney injury (CI-AKI) or for the prevention of death, need for dialysis, or persistent decline in kidney function at 90 days. Unlike in previous protocols, the study population excluded patients with preserved kidney function (it included patients with stage 3 or 4 chronic kidney disease; those with stage 3A were required to have diabetes mellitus which increases the risk of CI-AKI in patients with impaired kidney function). This enhanced the generalisability of the results among patients at higher risk for AKI and other adverse outcomes.

Evidence

KHA-CARI Guideline: KHA-CARI adaptation of the KDIGO Clinical Practice Guideline for Acute Kidney Injury. Langham RG1, Bellomo R, D’Intini V, Endre Z, Hickey BB, McGuinness S, Phoon RK, Salamon K, Wood J, Gallagher MP. Nephrology (Carlton). 2014 May; 19(5):261-5

Outcomes after Angiography with Sodium Bicarbonate and Acetylcysteine, Steven D. Weisbord, M.D., Martin Gallagher, M.D., Ph.D., Hani Jneid, M.D., et al. N Engl J Med 2018; 378:603-614 DOI: 10.1056/NEJMoa1710933
3

Do not give routine prophylactic antibiotics to a child after the first urinary tract infection if at low risk of recurrent urinary tract infections

Rationale

A conservative approach to the management of urinary tract infection (UTI) is warranted for most children. While the evidence related to risk factors for recurrent UTIs and the risks and benefits of antibiotic prophylaxis in children is limited, the existing evidence indicates that antimicrobial prophylaxis is not associated with decreased risk of recurrent UTI but is associated with an increased risk of resistant infections. Accordingly, the routine use of prophylactic antibiotics for children after a first UTI is not recommended.

Evidence

Conway PH, Cnaan A, Zaoutis T et al. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA. 2007; 298: 179-86

Diagnosis and Treatment of Urinary Tract Infection in Children. Steven McTaggart, Margie Danchin, Michael Ditchfield, Ian Hewitt, Joshua Kausman, Sean Kennedy, Peter Trnka1, Gabrielle Williams. Nephrology October 2014

Larkins, N.G., Hewitt, I.K. Urinary Tract Infection in Children. Curr Pediatr Rep 6, 259–268 (2018).
4

Do not intensively lower HbA1C<6.5% to <8.0% in patients with early (stage 1-3) chronic kidney disease as intense lowering increased the risk of hypoglycaemia and mortality, noting that the individual target depends on factors such as severity of CKD, macrovascular complications, comorbidities, life expectancy and others

Rationale

Diabetes mellitus is associated with significant cardiovascular morbidity and mortality and is the leading cause of chronic kidney disease (CKD) worldwide. Type 2 diabetes is also increasing in prevalence. Evidence indicates that tight glycaemic control in diabetic patients results in clinically significant preservation of kidney function. As such, patients with stage 1–3 CKD stemming from type 1 or type 2 diabetes mellitus should aim to achieve a HbA1c target of approximately 6.5% to <8.0%.

Caution is recommended against intensively lowering HbA1c levels below this target range because of proven increased risks of hypoglycaemia and possibly death. While a lower HbA1c target (<6.5% or <7%) may be preferred in some patients, less stringent glycaemic goals (<7.5% or <8%) may be appropriate for others, especially those with a history of hypoglycaemia, long duration of diabetes, advanced atherosclerosis or advanced age/fragility.

SGLT2 inhibitors are first-line therapy for organ protection in patients with CKD (eGFR >= 30 ml/min/1.73m2 and diabetes) in addition to metformin therapy because of its glucose-lowering effects.

Evidence

de Boer IH, Caramori ML, Chan JCN, Heerspink HJL, Hurst C, Khunti K, Liew A, Michos ED, Navaneethan SD, Olowu WA, Sadusky T, Tandon N, Tuttle KR, Wanner C, Wilkens KG, Zoungas S, Lytvyn L, Craig JC, Tunnicliffe DJ, Howell M, Tonelli M, Cheung M, Earley A, Rossing P. Executive summary of the 2020 KDIGO Diabetes Management in CKD Guideline: evidence-based advances in monitoring and treatment. Kidney Int. 2020 Oct;98(4):839-848

KHA-CARI Guideline: Early chronic kidney disease: Detection, prevention and management. Johnson DW, Atai E, Chan M, Phoon RKS, Scott C, Toussaint ND, Turner GL, Usherwood T, Wiggins KJ. Nephrology 2013; 18(5): 340-50

UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998; 352 (9131): 854–65. 35. UKPDS. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)
5

Do not prescribe aspirin therapy for primary prevention of cardiovascular disease in patients with stage 1-3 chronic kidney disease as there is no proven benefit and it is associated with increased risk of impaired haemostasis

Rationale

Chronic kidney disease is a well‐known independent cardiovascular risk factor. Evidence for anti‐platelet therapy indicates that low‐dose aspirin reduces the risk of cardiovascular disease (CVD) by 25–33%, especially in patients with established CVD or those at high risk. In patients with CKD such potential benefits need to be carefully weighed against an increased risk of bleeding. A meta-analysis of serious vascular events and major bleeds in 22 primary and secondary prevention trials involving a combined 120,000 individuals has found that in primary prevention without previous disease, aspirin is of uncertain net value. Moreover, high cumulative exposure to nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with an increased risk for rapid CKD progression in the community-based elderly.

Evidence

Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Antithrombotic Trialists’ Collaboration. The Lancet Vol 373, Issue 9678, P1849-1860, May 30, 2009

Gooch K, et al. NSAID use and progression of chronic kidney disease. Am J Med. 2007 Mar;120(3): 280.e1-7. PMID: 17349452

KHA-CARI Guideline: Early chronic kidney disease: Detection, prevention and management. Johnson DW, Atai E, Chan M, Phoon RKS, Scott C, Toussaint ND, Turner GL, Usherwood T, Wiggins KJ. Nephrology 2013; 18(5): 340-50

KHA-CARI Guideline: Medical therapies to reduce chronic kidney disease progression and cardiovascular risk: anti-platelet therapy. Phoon R, Johnson D. Chronic Kidney Disease Guideline May 2013

How this list was developed

The Australian and New Zealand Society of Nephrology (ANZSN) Clinical Policy and Advisory Committee worked with the RACP, as part of the Evolve Program, to develop a long list of low-value practices and interventions that pertain to the specialty. Through extensive research and redrafting, the list was condensed to the top-5 recommendations for reducing low-value practices in nephrology. Dr Paul Collett was the initial Lead Fellow for development of these Evolve Recommendations on behalf of ANZSN, and Dr David Tunnicliffe has now taken this role.

The list of recommendations was then subject to an extensive review process that involved key College societies with an interest or professional engagement with nephrology as well as health equity. It was then further consulted with other medical colleges through Choosing Wisely Australia. Feedback received in the consultations led to further research and finetuning of the list, which was then finalised and approved by the Caring for Australians and New ZealandeRs with kidney Impairment (CARI) Guidelines – a consortium of ANZSN, Kidney Health Australia and BEAT CKD.

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