Recommendations for culturally safe clinical kidney care for First Nations Australians: a guideline summary

Abstract Introduction First Nations Australians display remarkable strength and resilience despite the intergenerational impacts of ongoing colonisation. The continuing disadvantage is evident in the higher incidence, prevalence, morbidity and mortality of chronic kidney disease (CKD) among First Nations Australians. Nationwide community consultation (Kidney Health Australia, Yarning Kidneys, and Lowitja Institute, Catching Some Air) identified priority issues for guideline development. These guidelines uniquely prioritised the knowledge of the community, alongside relevant evidence using an adapted GRADE Evidence to Decision framework to develop specific recommendations for the management of CKD among First Nations Australians. Main recommendations These guidelines explicitly state that health systems have to measure, monitor and evaluate institutional racism and link it to cultural safety training, as well as increase community and family involvement in clinical care and equitable transport and accommodation. The guidelines recommend earlier CKD screening criteria (age ≥ 18 years) and referral to specialists services with earlier criteria of kidney function (eg, estimated glomerular filtration rate [eGFR], ≤ 45 mL/min/1.73 m2, and a sustained decrease in eGFR, > 10 mL/min/1.73 m2 per year) compared with the general population. Changes in management as result of the guidelines Our recommendations prioritise health care service delivery changes to address institutional racism and ensure meaningful cultural safety training. Earlier detection of CKD and referral to nephrologists for First Nations Australians has been recommended to ensure timely implementation to preserve kidney function given the excess burden of disease. Finally, the importance of community with the recognition of involvement in all aspects and stages of treatment together with increased access to care on Country, particularly in rural and remote locations, including dialysis services.


Target population preferences and views:
The Kidney Health Australia (KHA) Yarning Kidneys(1-3) and Catching Some Air(4) informed scope of the guidelines and the development of guideline recommendations.The literature searches included qualitative studies addressing patient and caregiver perspectives.The Work Group also included First Nations Australians with lived experience of kidney disease.CARI Guidelines also feedback to communities involved in the initial community consultation process to ensure the patient preferences and views were considered and addressed in the guidelines.
Target users: The guidelines may be used by healthcare workers caring for First Nations Australians with chronic kidney disease.The guidelines are also aimed at health systems and health policy to inform standards of care and clinical decisions related to holistic care for First Nations Australians with kidney disease.Health professionals, and Indigenous Health Experts were involved in the peer review of the guidelines, and invited to provide comment and feedback in the draft through professional societies, and peak organisations including the Strengths and Limitations of the evidence: Critical appraisal of the evidence is reported in the evidence tables (Appendix C; https://www.cariguidelines.org/first-nations-australiansguidelines-appendix-c/).A Summary of the Findings Tables for each topic is reported in Appendix D (https://www.cariguidelines.org/first-nations-australians-guidelines-appendix-d/) for the full guidelines.The adapted evidence to decision framework (Four C's) includes discussion of benefits and harms from the clinical evidence as well as the limitations of the data using the GRADE Assessment.
Formulations of recommendations: Recommendations were formulated based on an adapted GRADE Evidence to Decision Framework to include the community voice and other cultural Safety implications.The full guidelines detail each aspects of the Evidence to Decision Framework in detail for all guideline recommendations.
Consideration of benefits and harms: Clinical evidence is a domain of the Four C's Evidence to Decision Framework.

Link between recommendations and evidence:
The evidence for each subtopic was systematically screened, extracted and summarised with appraisal, and recommendations used the GRADE Assessment to qualify the certainty of the evidence in relation to the recommendation.Evidence tables are provided for each guideline subtopic.
External Review: Six peer reviewers with expertise in the subtopic/field were identified by the Work Group (including nephrologists, Indigenous Health) from hospitals and Universities around Australia.Reviewers were invited to complete a review form, and/or provide comment directly on the draft guideline manuscript.Final drafts were posted for public review for one month.Comments, suggestions and feedback were integrated into the final versions of the manuscript.
Updating procedure: This guideline will be reviewed and updated to account for new evidence relating to the topic that may: • Warrant inclusion of additional recommendations; • Alter the strength of a recommendation, i.e. upgrade a suggestion to a recommendation or conversely downgrade a recommendation to a suggestion.

• Warrant removal or change to a recommendation or suggestion;
There is no set timeline for updating, but the Working Group is committed to providing recommendations on transplantation upon the completion of the National Indigenous Transplant Taskforce studies and Return to Country Study.

Domain 4: Clarity of Presentation
Graded recommendations and suggestions are provided in a box at the beginning of each guideline subtopic, with reference to the population or subgroup where relevant.Where there is uncertainty in the evidence, this is reflected in the grade of the evidence available with the full guideline and may be supported by ungraded statements.

Domain 5: Applicability
Facilitators and barriers to application: These guidelines are based on the best available evidence, with consideration from the authors regarding potential barriers to application such as cost and time, and facilitators such as current practice.Further relevant details may be discussed within guideline subtopics.
Implementation advice/tools: Each guideline subtopic contains suggestions for implementation, and future research.
Resource implications: Each guideline recommendation includes Cost, capacity, equity and other considerations as a domain for the Four C's.Cost-effectiveness studies were included in the search and other implications for costs are discussed to inform guideline recommendation development.
Monitoring auditing criteria: Where relevant, the guidelines recommend audit criteria or contain suggestions for audit are discussed in the Cost, capacity, equity and other consideration domain.An overall statement about implementation and audit is provided in the guidelines

Domain 6: Editorial independence
The development of the CARI guideline for Recommendations for culturally safe kidney care for First Nations Australians was funded by Kidney Health Australia, who received a grant from the Federal Government.The funding bodies did not influence the content or scope of the guideline.

Summary of finding tables
Please see appendix of the full guidelines for details on the rating certainty of the evidence for each summary of finding available at the CARI Guidelines website (https://www.cariguidelines.org/first-nations-australians-guidelines-appendix-d)Cultural safety and responsive kidney health care

LOW
Involvement of members and their stories and Indigenous children improved the engagement and impact of the health promotion campaign.

VERY LOW
Interventions aimed at improving self-management improved some surrogate outcomes (blood pressure, HbA1c, c-reactive protein, quality of life).However, for some outcomes there were no impact (eGFR, urinary protein excretion).The long-term duration of these benefits are unclear as studies were usually of limited duration.(86) q. r.

MODERATE
Programs conducted within community-controlled health services, and which utilise a multidisciplinary team approach, to implement routine CKD-specific screening measures, alongside assigning dedicated healthcare staff responsible for this screening effectively increase the identification of CKD in at-risk patients, and subsequent management 1 report (85) 1 observational study (86) 1 descriptive study (87) q. r.

LOW
Programs embedded within a community health service and involve community healthcare staff to deliver education and training to patients, effectively increase patient empowerment and quality of life, through increasing patients' knowledge and ability to self-monitor their health 1 RCT (84) q. r.

LOW
APPENDIX CULTURALLY SAFE CLINICAL KIDNEY CARE GUIDELINES -Compliance with AGREE II reporting checklist (https://www.agreetrust.org/resource-centre/agree-reporting-checklist/)To ensure clinical practice aligns with the best available evidence; • To improve the identification, management of CKD among First Nations Australians with CKD • To provide recommendations on improved culturally safe and responsive care for First Nations Australians with CKD Questions: Research questions to determine scope of the guideline were developed by the guideline writing group comprised of nephrologists, endocrinologist, renal nurses, health economists, guideline methodologists, people with lived experience with kidney disease and informed by a nationwide community consultation.Further details of the research questions (PICOM/PECOM format) address in these guidelines are detailed in Table A1 available in Appendix A (https://www.cariguidelines.org/first-nations-australians-guidelines-appendix-a/) of the full guidelines.• Renal Nurses and Clinical Researchers: Melissa Arnold-Ujvari, Janet Kelly, The University of Adelaide, SA, Liz Rix, Southern Cross University, QLD, The University of Adelaide, SA • Renal dietitian and Researcher: Kelly Lambert, University of Wollongong, NSW, Illawarra Health and Medical Research Institute, NSW • Health Economists: Martin Howell, The Children's Hospital at Westmead, The University of Sydney, Sydney, NSW • Guideline methodologists: Martin Howell, The Children's Hospital at Westmead, The University of Sydney, Sydney, NSW; David J Tunnicliffe, The Children's Hospital at Westmead, The University of Sydney, Sydney, NSW; Adela Yip The Children's Hospital at Westmead, The University of Sydney, Sydney, NSW, Search strategies and evidence synthesis for all guideline subtopics.

Table A1 .
Summary of findings -Interventions for addressing inequity and institutional racism

Table A3 .
Summary of findings -Person/family/community centred engagement and involvement in managing chroni c kidney disease

Table A4 .
Summary of findings -Transport and accommodation services for First N ations Australians

Table A5 .
Summary of findings -First Nations kidney health workforce

Table A6 .
Summary of findings -Factors associated with the incidence and progression of CKD in Indigenous peoples.

Table A7 .
Summary of findings -Screening and early detection programmes for chronic kidney disease among First Nations Australians

Table A8 .
Summary of findings -Referral practices for First Nations Australians with chronic kidney disease

Table A9 .
Summary of findings -Public awarenessto enable First Nations Australians to access information about kidney disease prior to screening and diagnosis

Table A10 .
Summary of findings -Education interventions that deliver knowledge to support First Nations Peoples with CKD and their community

Table A11 .
Summary of findings -Education interventions that deliver knowledge to support First Nations Peoples and their community

Table A12 .
Summary of findings table -Self-management programmes and interventions

Table A13 .
Summary of findings -Models of carechronic kidney disease (pre -dialysis)

Table A14 .
Summary of findings -Models of care (Kidney failure) nurse supported, remote area dialysis models are clinically safe, with no mortality disadvantage, and allow people to have dialysis on Country.Community controlled, nurse supported, remote area dialysis models are cost effective when total health expenditure is considered.Urban community-based home haemodialysis is a safe model, which does not increase mortality when compared to conventional home haemodialysis.Urban community-based home haemodialysis is acceptable to First Nations communities and may reduce the treatment burden of in-centre dialysis.Adopting a primary care supported, telehealth model of dialysis care does not lead to health disadvantage in term of clinical outcomes or mortality.Telehealth should be considered as an option to augment traditional faceto-face care.Mobile dialysis units may facilitate return to Country and have important psychosocial benefits for patients and community.However, successful uptake of mobile dialysis requires local accommodation, transport, and sufficient workforce support.