Clinical Commander

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neph.ckd.core.v1

Chronic Kidney Disease (KDIGO G/A staging + GDMT)

nephrologychronicadultoutpatienttransition
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Manifest cites KDIGO 2024 + FLOW + FIDELIO/FIGARO + DAPA-CKD + EMPA-KIDNEY + FINEARTS-HF + SHARP + SPRINT (renal subgroup). Full PMIDs embedded 2026-05-12. DEPTH-PASS-2 2026-05-16 (shard-07-cardio-chronic, neph.ckd.core.v1 deepened to golden-template contract mirroring cardio.htn.core.v1) added: (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (18 verified PMIDs, named trials + effect sizes + 95% CI, retrieval-dated 2026-05-16, Consensus→WebSearch fallback logged); design_brief field repointed to src/lib/dossiers/neph.ckd.core.v1._design-brief.md; (2) neph.ckd.core.v1 differentials+ros+finding-lrs seed files (11 differentials w/ cohort-anchored CKD-cause-partition priors, 13 ROS, 34 LR rows = 25 LR+(>1)/25 LR−(<1), 3 conditional-dependency rules, T_test≈5%/T_treat≈20%); (3) 2nd regimen axis ckd_comorbidity_phenotype (drug × cause/eGFR/comorbidity gating as data — diabetic vs non-diabetic CKD, HF overlap, hyperkalaemia-prone, advanced-G4/5 deprescribing, pregnancy); (4) RxCUI bugs fixed vs DrugEffectProfile registry: finerenone 2168780→2562811 (4×), sodium_bicarbonate 203394→9820, patiromer 1996253→1716203; rxnav:validate grep confirmed OK; (5) KDIGO-2024 content refresh: SGLT2i diabetes-agnostic eGFR≥20 (continue if later <20 unless KRT), finerenone DKD-only gate, GLP-1 FLOW, statin-by-age fixed-dose, KFRE-guided referral, 2021 race-free CKD-EPI; evidence.pmids 10→18, stale POINT/REDUCE/SPRINT removed, FIDELIO 33069562→33264825 + FINEARTS 39264738→39225278 corrected; dose-effect rationale enriched with eGFR-slope/UACR%/HR-95%CI on every regimen drug. KFRE calculator (calc_kfre) referenced in manifest but not present in clinical-tools-registry.ts as calc.kfre — KFRE 2-year + 5-year (Tangri JAMA 2011 / 2016 international validation) needs registration; flag to C.4 calc-quality chat. Without it, risk-stratification phase relies on plain-language description. Cardiovascular-Kidney-Metabolic (CKM) syndrome (2023 AHA Presidential Advisory; Ndumele Circulation 2023) is referenced in FOLLOWUP phase as comprehensive review, but a dedicated cardio.ckm.core.v1 sibling engine is not yet authored. Suggested ticket to B.1 cardio chat. GLP-1 RA for kidney protection: FLOW NEJM 2024 demonstrated semaglutide reduces major kidney events 24% vs placebo in T2D-CKD; KDIGO 2024 + ADA 2026 endorse. Authored into G3a-G4 axes. No dedicated CKD-engine test file (covered by dossier-contract + ckd-staging.service.ts unit tests). Citation + RxCUI remediation 2026-05-22: all 18 evidence PMIDs re-verified live via PubMed and confirmed on-topic (KDIGO 2024 CKD 38490803, DAPA-CKD 32970396, EMPA-KIDNEY 36331190, FIDELIO 33264825, Tangri KFRE 26757465 spot-checked — all correct). Three regimen RxCUIs that were still invalid/mis-attributed despite the 2026-05-16 pass were corrected to RxNav-verified codes: sodium_bicarbonate 9820(invalid)→36676, cholecalciferol 861025(=metformin-solution)→2418, sevelamer 4019(invalid)→214824.

Entry points (4)

  • lab_abnormality
    eGFR <60 sustained ≥3 months (KDIGO 2024)
    egfr_low
  • lab_abnormality
    UACR ≥30 mg/g sustained ≥3 months (KDIGO 2024)
    uacr_elevated
  • problem_list
    Existing CKD on problem list — titration visit (KDIGO 2024)
    ckd
  • problem_list
    DM2 with kidney disease — DKD (ADA 2026 §11)
    diabetic_nephropathy

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    eGFR + KFRE risk (Tangri JAMA 2016) + statin eligibility ages 50–79 (SHARP, Baigent Lancet 2011)
  • creatininerequired
    lab • used at CONTEXT
    CKD-EPI 2021 race-free eGFR — KDIGO 2024 staging foundation
  • uacrrequired
    lab • used at CONTEXT
    KDIGO 2024 A1/A2/A3 albuminuria stage; gates SGLT2i + finerenone
  • sbprequired
    vital • used at CONTEXT
    KDIGO 2024 BP target SBP <120 if tolerated; gates RAS titration
  • potassiumrequired
    lab • used at CONTEXT
    RAS + finerenone + MRA gating; baseline before titration (KDIGO 2024)
  • dm2required
    history • used at CONTEXT
    DKD = primary indication for SGLT2i (DAPA-CKD, Heerspink NEJM 2020) + finerenone (FIDELIO-DKD, Bakris NEJM 2020) + GLP-1 (FLOW)
  • current_medsrequired
    medication • used at CONTEXT
    Detect existing RAS/SGLT2i; flag NSAIDs, contrast risk (KDIGO 2024)
  • hba1c
    lab • used at INITIAL_WORKUP
    DM control gates GLP-1 (FLOW NEJM 2024) + SGLT2i benefit independent of glycemic effect (DAPA-CKD)
  • phosphorus
    lab • used at INITIAL_WORKUP
    CKD-MBD assessment stage 4–5 (KDIGO 2017 CKD-MBD)
  • pth
    lab • used at INITIAL_WORKUP
    CKD-MBD; secondary hyperparathyroidism (KDIGO 2017 CKD-MBD)
  • hemoglobin
    lab • used at INITIAL_WORKUP
    Anemia of CKD; iron + ESA threshold (KDIGO 2012 Anemia)
  • bicarbonate
    lab • used at INITIAL_WORKUP
    Metabolic acidosis stage 3b–5; oral bicarb target HCO3 22–29 (KDIGO 2024)
  • cv_disease
    history • used at CONTEXT
    Statin + ASCVD risk assessment (SHARP, Baigent Lancet 2011)

12-phase flow (12)

  1. 1FRAME
    Confirm CKD: eGFR <60 OR UACR ≥30 OR structural marker, sustained ≥3 months (KDIGO 2024)
    inputs: creatinine, uacr
    advance: KDIGO 2024 chronicity criteria met (not acute injury)
  2. 2ENTRY
    Trigger from labs / problem list / DM2 follow-up (ADA 2026 §11)
    inputs: age
    advance: Demographics + entry trigger captured
  3. 3CONTEXT
    Capture vitals, full med list, comorbidities — DM, HTN, ASCVD, gout, glomerular disease (KDIGO 2024)
    inputs: sbp, potassium, creatinine, uacr, dm2, current_meds, cv_disease
    advance: Comorbidity + drug-class review complete
  4. 4RED_FLAGS
    Detect AKI on CKD; severe hyperK; uremic complications; advanced stage 5 needing RRT (KDIGO 2012)
    inputs: creatinine, potassium
    advance: No emergencies or routed to neph.aki.core.v1 / dialysis prep
  5. 5INITIAL_WORKUP
    CMP, UACR, lipid, A1c, CBC, iron, Ca/Phos/PTH, vitamin D, bicarbonate, urinalysis (KDIGO 2024)
    inputs: hba1c, phosphorus, pth, hemoglobin, bicarbonate
    actions: panel.renal, panel.cbc, panel.iron
    advance: Baseline labs returned
  6. 6BRANCHING_WORKUP
    Etiology-specific workup if newly diagnosed: DKD vs nephritic vs nephrotic vs PKD vs ischemic; biopsy if unclear (KDIGO 2024)
    advance: Etiology established or referred
  7. 7DIFFERENTIAL
    KDIGO 2024 G/A stage assignment via ckd-staging.service.ts; subtype: DKD / HTN / GN / cystic / ischemic
    inputs: creatinine, uacr
    actions: calc.ckd_epi_2021
    advance: G + A stage documented + etiology
  8. 8RISK_STRATIFICATION
    KFRE 2- and 5-year risk (Tangri JAMA 2016); cardiovascular risk; ESRD planning threshold KFRE 2y >5–10%
    inputs: age, creatinine, uacr
    advance: KFRE risk + CV risk documented
  9. 9TREATMENT
    BP <120 if tolerated — RAS (REIN, Ruggenenti Lancet 1998); SGLT2i if eGFR ≥20 (DAPA-CKD); finerenone if DKD + UACR ≥30 + K<5 (FIDELIO-DKD); GLP-1 if DM-CKD (FLOW); statin ages 50–79 (SHARP); bicarb if HCO3<22; treat anemia (KDIGO 2012) + CKD-MBD (KDIGO 2017)
    inputs: sbp, potassium, creatinine, uacr, hba1c
    actions: calc.ckd_epi_2021
    advance: GDMT pillars assigned at lowest tolerated doses
  10. 10DISPOSITION
    Nephrology referral G3b/A3 or unclear etiology; vascular access referral G4–5; transplant work-up KFRE >10% (KDIGO 2024)
    advance: Referrals + visit cadence set
  11. 11MONITORING
    BMP within 1–2 weeks of titration; UACR + eGFR q3–6m; K trend on RAS + finerenone; A1c q3m if DM (KDIGO 2024)
    inputs: creatinine, potassium, uacr
    actions: panel.renal
    advance: Monitoring schedule documented
  12. 12FOLLOWUP
    Cadence by KDIGO 2024 stage; vaccinations (flu/pneumo/HBV/COVID); patient education; CKM review (Ndumele Circulation 2023)
    advance: Follow-up scheduled