Clinical Commander

All dossiers
neph.aki.core.v1

Acute Kidney Injury (KDIGO)

nephrologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest cites KDIGO 2026 AKI/AKD draft (public review through April 2026; integrate adopted draft items where mature, mark for re-validation when finalized) + KDIGO 2012 binding. Citation + RxCUI remediation 2026-05-22: every evidence PMID re-verified live via PubMed; fabricated/mis-attributed codes corrected (KDIGO-2012 22498880=HAPE-metabolomics→22890468, IDEAL-ICU 30304886=goose-virus→30304656, CONFIRM 33657293=ATTIRE-albumin→33657294, STARRT 32325664=pancreatic-cancer→32668114, AKIKI 26913820=microalgae→27181456, Gonzalez-AIN 18497849→18185501; removed unrecoverable 17434933=DNA-compaction). RxCUIs corrected to RxNav-verified codes: lactated_ringers 1807508→847630, sodium_chloride 7407→9863, albumin_25% 480→828529. Calculators surfaced by aki.engine.ts (calc_fena, calc_feurea, calc_bun_cr_ratio, calc_delta_delta, calc_corrected_ag, calc_ttkg, calc_winter, calc_fluid_overload_pct, calc_shock_index) are referenced in the runtime engine layer but NOT yet in this dossier calculators[] — registry IDs do not yet match dossier-side names (calc.fena vs calc_fena). C.4 calc-quality chat should reconcile the naming pair. Drug-induced AIN offender list (consumed_at CONTEXT, drives ain regimen step): PPIs (omeprazole > rabeprazole > pantoprazole, all class effect), NSAIDs (esp. propionic acid derivatives), beta-lactams (penicillins, cephalosporins, especially cefepime), fluoroquinolones, sulfonamides, TMP-SMX, vancomycin, rifampin, indinavir, allopurinol, mesalamine/5-ASA, ICIs (anti-PD-1/PD-L1, anti-CTLA-4 — increasingly common, may need ICI-pi-AKI differential against immune-related GN). HRS-AKI cross-references gi.hepatorenal-syndrome.core.v1 (B.7 GI/hep ownership). AKI dossier holds routing logic; deepening HRS pharmacology (terlipressin titration safety, octreotide-midodrine, norepinephrine targets) lands in the HRS dossier. RPGN phenotype branches to renal.rpgn.core.v1 (manifest is scaffold; renal.rpgn dossier deepened 2026-05-12 with subtype ICD-10/SNOMED/LOINC + RAVE/CYCLOPS/PEXIVAS/MAINRITSAN PMIDs). No targeted disease test file (covered by tests/dossiers/integration/neph-aki-integration.test.ts + contract).

Entry points (5)

  • lab_abnormality
    Creatinine rise ≥0.3 in 48h or ≥1.5x baseline in 7d (KDIGO 2012)
    creatinine_rise
  • lab_abnormality
    Oliguria <0.5 mL/kg/h ≥6h (KDIGO 2012)
    oliguria
  • symptom
    Anuria / decreased urine output (KDIGO 2012)
    anuria
  • lab_abnormality
    Hyperkalemia or metabolic acidosis on routine BMP (KDIGO 2012 AEIOU)
    hyperkalemia
  • problem_list
    AKI on problem list (continuation visit)
    aki

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Drug dosing + biopsy candidacy + RRT decisions (KDIGO 2012)
  • creatininerequired
    lab • used at CONTEXT
    KDIGO staging is creatinine trajectory (KDIGO 2012)
  • baseline_creatininerequired
    lab • used at CONTEXT
    Required to calculate Cr ratio for KDIGO stage (KDIGO 2012)
  • potassiumrequired
    lab • used at RED_FLAGS
    Hyperkalemia is AEIOU dialysis indication; emergency Rx threshold (KDIGO 2012)
  • bicarbonaterequired
    lab • used at RED_FLAGS
    Severe acidosis (pH<7.1) is AEIOU dialysis indication (KDIGO 2012)
  • urine_outputrequired
    vital • used at CONTEXT
    KDIGO oliguria criteria + post-obstruction monitoring (KDIGO 2012)
  • sbprequired
    vital • used at CONTEXT
    Pre-renal hypoperfusion screen + sepsis/cardiogenic shock (KDIGO 2012)
  • current_medsrequired
    medication • used at CONTEXT
    Nephrotoxin review (NSAID/ACEi/ARB/aminoglycoside/contrast/PPI) (KDIGO 2012)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Sediment analysis branches mechanism (casts, RBC, WBC, eos) (KDIGO 2012)
  • urine_sodium
    lab • used at INITIAL_WORKUP
    FENa/FEUrea distinguishes pre-renal from intrinsic ATN (KDIGO 2012)
  • renal_us
    imaging • used at BRANCHING_WORKUP
    Hydronephrosis → postrenal phenotype (KDIGO 2012)
  • cirrhosis
    history • used at CONTEXT
    HRS-AKI requires albumin challenge + terlipressin (AASLD 2023)
  • ckd
    history • used at CONTEXT
    AKI-on-CKD changes baseline + drug dosing (KDIGO 2024)
  • recent_contrast
    history • used at CONTEXT
    Contrast-associated AKI vs other ATN (KDIGO 2012)

12-phase flow (12)

  1. 1FRAME
    Confirm AKI by KDIGO criteria (Cr +0.3/48h or 1.5x/7d or oliguria) and exclude pseudoAKI
    inputs: creatinine, baseline_creatinine
    advance: KDIGO criteria met and not artifactual
  2. 2ENTRY
    Recognize triggering creatinine rise / oliguria / hyperkalemia
    inputs: creatinine, urine_output
    advance: AKI flagged + demographics captured
  3. 3CONTEXT
    Capture vitals, baseline kidney function, comorbidities, full med list, recent contrast/sepsis
    inputs: sbp, creatinine, baseline_creatinine, potassium, current_meds, cirrhosis, ckd, recent_contrast
    advance: Comorbidity + nephrotoxin review complete
  4. 4RED_FLAGS
    Screen for AEIOU emergencies: severe hyperK, refractory acidosis, uremic complications, volume overload, anuria, RPGN sediment, bilateral hydronephrosis
    inputs: potassium, bicarbonate, urine_output
    actions: protocol.hyperkalemia
    advance: No AEIOU emergency or routed to RRT/protocol
  5. 5INITIAL_WORKUP
    BMP serial Cr, urinalysis with micro, FENa/FEUrea, UPCR, CBC, lactate if septic
    inputs: urinalysis, urine_sodium
    actions: panel.renal, panel.cbc, calc.anion_gap
    advance: Mechanism class (pre/intrinsic/post) provisional
  6. 6BRANCHING_WORKUP
    Renal US for obstruction; urine micro for casts; complement/ANCA/anti-GBM if GN; CK if rhabdo; biopsy if unclear
    inputs: renal_us
    actions: workup.aki, workup.aki_on_ckd
    advance: Phenotype assigned (prerenal/ATN/AIN/GN/postrenal/HRS)
  7. 7DIFFERENTIAL
    Phenotype: prerenal / ATN / AIN / GN (→ renal.rpgn) / postrenal / HRS-AKI / cardiorenal / TMA
    advance: Phenotype documented
  8. 8RISK_STRATIFICATION
    KDIGO stage 1/2/3, identify AEIOU dialysis indications, predict AKD/CKD progression
    inputs: creatinine, baseline_creatinine
    actions: calc.ckd_epi_2021
    advance: Stage + AEIOU status documented
  9. 9TREATMENT
    Stop nephrotoxins; volume management by phenotype; phenotype-specific Rx (crystalloid for prerenal; relieve obstruction; albumin+terlipressin for HRS; steroids for AIN; immunosuppression for GN); RRT if AEIOU
    inputs: potassium, bicarbonate, sbp
    actions: protocol.hyperkalemia
    advance: Phenotype-specific plan executed; RRT initiated if indicated
  10. 10DISPOSITION
    ICU for severe AEIOU; nephrology consult stage 2-3 or unclear etiology; urology for obstruction; hepatology for HRS
    advance: Disposition + consults set
  11. 11MONITORING
    Daily Cr until stable, strict I/O, daily weight, K + acid-base q6-12h while titrating, drug-level adjustment
    inputs: creatinine, potassium, urine_output
    actions: panel.renal
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    Recheck Cr 1 week post-discharge; nephrology outpatient; 3-month reassessment for CKD progression; med-rec post-AKI
    advance: Follow-up scheduled and patient educated