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renal.aki.intrinsic.atn.v1

Acute Kidney Injury — Intrinsic ATN Mechanism

nephrologyacuteadultacuteinpatient
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Phase C wave-7 2026-05-15: mechanism-specific deep-dive carved from renal.aki.v1; covers ischemic ATN (sepsis-AKI most common ICU) + nephrotoxic ATN (aminoglycoside, vancomycin AUC-targeted, contrast-induced) + rhabdomyolysis + TLS + cisplatin/methotrexate + myeloma cast + pigment + calciphylaxis. Diagnostic pivot from pre-renal: FeNa >2% + BUN:Cr <15:1 + urine osm <350 + muddy-brown granular casts + tubular epithelial cells; recovery 1-3 weeks with supportive care (KDIGO 2012 AKI; Carvounis 2002). Phenotype routing: TLS → heme.tumor-lysis-syndrome.core.v1 (Cairo-Bishop + Coiffier JCO 2008); sepsis-AKI → id.sepsis.core.v1 (SSC 2026); glomerular → renal.rpgn.core.v1 (KDIGO 2021 GN); parent all-cause → renal.aki.v1; pre-renal sibling → renal.aki.prerenal.v1. Evidence anchored on KDIGO 2012 AKI + STARRT-AKI/AKIKI/IDEAL-ICU (no benefit to early RRT) + PRESERVE 2018 (negative for prophylactic NaHCO3+NAC) + Rybak 2020 (vanco AUC) + Coiffier 2008 (TLS/rasburicase) + Howard 2011 (tumor lysis) + Bosch NEJM 2009 (rhabdomyolysis) + SMART/SALT-ED 2018 (balanced crystalloid). Schema-blocked calculator queue: KDIGO AKI staging (calc.kdigo_aki), FENa/FEUrea (calc.fena/calc.feurea), Cairo-Bishop TLS classification (calc.cairo_bishop_tls), vancomycin AUC (calc.vanco_auc) — not in clinical-tools-registry; surfaced as text in severity_triggers + required_assessments until registry expansion (owner: shard-0 clinical-tools-registry maintainer). Stub manifest created at prisma/seed/manifests/renal.aki.intrinsic.atn.v1.ts; full seed manifest deferred to a later terminology-completion pass. INTEGRATED tier: regimen axis intrinsic_atn_supportive_and_specific with 6 steps + 5 settings + 12 severity triggers + 5 sibling differentiations + 11 PubMed-verified evidence PMIDs + dedicated test file. Citation + RxCUI remediation 2026-05-22: every evidence PMID re-verified live via PubMed (fabricated/mis-attributed codes replaced — STARRT 32325664→32668114, AKIKI 26913820→27181456, IDEAL-ICU 30304886→30304656, Rybak 28538076→32658968, Coiffier 18421052/Cairo 28679498→18509186, Howard 26960915→21561350, Bosch 19474385→19571284; removed unrecoverable 30094008/30577006/27485415/31978347/24579847/26606878). RxCUIs corrected to RxNav-verified codes: lactated_ringers 1807508→847630, sodium_chloride 7407→9863, leucovorin 6851→6313, mannitol 36567→6628, sodium_bicarbonate 36675→36676, rasburicase 253182→283821.

Entry points (6)

  • lab_abnormality
    Muddy-brown granular casts + renal tubular epithelial cells on urine micro (KDIGO 2012 AKI)
    muddy_brown_casts
  • lab_abnormality
    FeNa >2% + BUN:Cr <15 + urine osm <350 (KDIGO 2012 AKI; Carvounis 2002)
    fena_gt_2
  • history
    Sepsis / septic shock + sustained hypoperfusion + AKI (SSC 2026; KDIGO 2012 AKI)
    sepsis_with_aki
  • medication
    Aminoglycoside, vancomycin trough/AUC, contrast, cisplatin, methotrexate exposure (KDIGO 2012 AKI)
    nephrotoxin_exposure
  • lab_abnormality
    CK >5000 U/L + myoglobinuria (rhabdomyolysis) (KDIGO 2012 AKI)
    ck_gt_5000
  • lab_abnormality
    HyperK + hyperphos + hyperuricemia + hypoCa post-chemo (Cairo-Bishop TLS)
    tls_metabolic_panel

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Drug-dose adjustment + RRT candidacy + nephrotoxin tolerance (KDIGO 2012 AKI)
  • creatininerequired
    lab • used at CONTEXT
    KDIGO staging is Cr trajectory; tubular recovery 1-3 weeks (KDIGO 2012 AKI)
  • baseline_creatininerequired
    lab • used at CONTEXT
    Required to compute Cr ratio for KDIGO stage + judge baseline (KDIGO 2012 AKI)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Muddy-brown granular casts + RTEC define ATN sediment (KDIGO 2012 AKI)
  • urine_sodium
    lab • used at INITIAL_WORKUP
    FeNa >2% supports ATN over pre-renal (KDIGO 2012 AKI; Carvounis 2002)
  • urine_osmolality
    lab • used at INITIAL_WORKUP
    Urine osm <350 (isosthenuria) supports tubular dysfunction (KDIGO 2012 AKI)
  • potassiumrequired
    lab • used at RED_FLAGS
    TLS hyperK + rhabdo hyperK + AEIOU threshold (KDIGO 2012 AKI; Cairo-Bishop)
  • phosphate
    lab • used at RED_FLAGS
    TLS hyperphos + AKI of any cause; also low phos with refeeding (Cairo-Bishop)
  • uric_acid
    lab • used at INITIAL_WORKUP
    TLS hyperuricemia >8 mg/dL or 25% rise (Cairo-Bishop)
  • ck
    lab • used at INITIAL_WORKUP
    Rhabdomyolysis CK >5000 + myoglobinuria (KDIGO 2012 AKI)
  • lactate
    lab • used at INITIAL_WORKUP
    Sepsis / shock screening + cisplatin lactic acidosis (SSC 2026)
  • sbprequired
    vital • used at CONTEXT
    Hemodynamic context for ischemic ATN + sepsis (KDIGO 2012 AKI; SSC 2026)
  • urine_outputrequired
    vital • used at CONTEXT
    Oliguria criteria + post-injury trajectory (KDIGO 2012 AKI)
  • current_medsrequired
    medication • used at CONTEXT
    Aminoglycoside, vanco, contrast, cisplatin, methotrexate, NSAID, ACEi review (KDIGO 2012 AKI)
  • recent_contrast
    history • used at CONTEXT
    CI-AKI (24-72h post-contrast) phenotype (KDIGO 2012 AKI; PRESERVE NEJM 2018)
  • recent_chemo
    history • used at CONTEXT
    Cisplatin/methotrexate ATN + TLS post-chemo (Cairo-Bishop)
  • crush_or_exertion_or_seizure
    history • used at CONTEXT
    Rhabdomyolysis trigger (KDIGO 2012 AKI)
  • malignancy_hematologic
    history • used at CONTEXT
    TLS predisposing — bulky lymphoma, AML, ALL, high LDH (Cairo-Bishop)

12-phase flow (12)

  1. 1FRAME
    Confirm AKI by KDIGO 2012 staging AND mechanism profile supports intrinsic ATN (FeNa >2%, BUN:Cr <15, muddy-brown casts) (KDIGO 2012 AKI; Carvounis 2002)
    inputs: creatinine, baseline_creatinine
    advance: KDIGO criteria met + ATN profile (KDIGO 2012 AKI)
  2. 2ENTRY
    Cr rise with ischemic / nephrotoxic / rhabdo / TLS / pigment / cast nephropathy exposure (KDIGO 2012 AKI)
    inputs: creatinine, urinalysis
    advance: Intrinsic ATN phenotype suspected (KDIGO 2012 AKI)
  3. 3CONTEXT
    Hemodynamic history (sepsis, prolonged hypotension), nephrotoxin med review (aminoglycoside / vanco / contrast / cisplatin / methotrexate), trigger history (crush, seizure, chemo, hemolysis) (KDIGO 2012 AKI; SSC 2026; Cairo-Bishop)
    inputs: sbp, current_meds, recent_contrast, recent_chemo, crush_or_exertion_or_seizure, malignancy_hematologic
    advance: Triggering exposure documented (KDIGO 2012 AKI)
  4. 4RED_FLAGS
    AEIOU emergencies (K >6.5, pH <7.1, anuria, uremic complications); rhabdo hyperK; TLS quadrad (KDIGO 2012 AKI; Cairo-Bishop)
    inputs: potassium, phosphate, uric_acid
    actions: protocol.hyperkalemia
    advance: AEIOU screen + TLS labs complete (KDIGO 2012 AKI)
  5. 5INITIAL_WORKUP
    BMP, urinalysis with microscopy (muddy-brown casts + RTEC), FeNa/FeUrea, CK + myoglobin if suspect rhabdo, uric acid + phos + LDH if TLS, lactate if septic, peripheral smear if hemolysis (KDIGO 2012 AKI; Cairo-Bishop)
    inputs: urinalysis, urine_sodium, urine_osmolality, ck, lactate, uric_acid
    actions: panel.renal, panel.cbc
    advance: ATN sub-phenotype suggested (KDIGO 2012 AKI)
  6. 6BRANCHING_WORKUP
    SPEP/UPEP + serum free light chains for myeloma cast nephropathy; haptoglobin + LDH for hemolysis-pigment; kidney biopsy if etiology unclear after 7-14 days (KDIGO 2012 AKI; KDIGO 2021 GN)
    advance: ATN sub-phenotype assigned (KDIGO 2012 AKI)
  7. 7DIFFERENTIAL
    ATN sub-phenotypes: ischemic / aminoglycoside / vancomycin AUC / CI-AKI / rhabdomyolysis / TLS / cisplatin-methotrexate / myeloma cast / pigment / calciphylaxis (KDIGO 2012 AKI; PRESERVE NEJM 2018; Cairo-Bishop)
    advance: Sub-phenotype documented (KDIGO 2012 AKI)
  8. 8RISK_STRATIFICATION
    KDIGO stage 1/2/3; AEIOU dialysis indications; expected recovery trajectory by sub-phenotype (1-3 weeks typical) (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
    inputs: creatinine
    actions: calc.ckd_epi_2021
    advance: Stage + sub-phenotype + recovery expectation documented (KDIGO 2012 AKI)
  9. 9TREATMENT
    Supportive care — discontinue/avoid nephrotoxin (or modify); cautious IVF (NOT over-resuscitation; FACTT-style positive balance harm); rhabdo IVF + LR; TLS rasburicase + IVF; cisplatin leucovorin/amifostine; pigment alkalinization controversial; KRT per AEIOU; iso-osmolar low-volume contrast if needed (KDIGO 2012 AKI; STARRT-AKI NEJM 2020; PRESERVE NEJM 2018; Cairo-Bishop)
    inputs: creatinine, potassium, urine_output
    actions: protocol.hyperkalemia
    advance: Sub-phenotype-specific plan executed (KDIGO 2012 AKI)
  10. 10DISPOSITION
    ICU for severe sepsis-ATN / refractory AEIOU / TLS with imminent RRT; ward for stable ATN; outpatient for recovery (KDIGO 2012 AKI; SSC 2026)
    advance: Disposition + consults set (KDIGO 2012 AKI)
  11. 11MONITORING
    Daily Cr until recovery (1-3 wks typical), strict I/O, daily weight, K + acid-base q6-12h during titration, drug-level adjustment (vanco AUC, aminoglycoside trough), CK trajectory rhabdo, TLS labs q4-6h (KDIGO 2012 AKI; Cairo-Bishop)
    inputs: creatinine, potassium, urine_output
    actions: panel.renal
    advance: Monitoring orders documented (KDIGO 2012 AKI)
  12. 12FOLLOWUP
    Recheck Cr 1 wk post-discharge; nephrology outpatient; 3-month + 12-month eGFR for CKD progression; permanent NSAID/aminoglycoside avoidance counselling; contrast-avoidance card if CI-AKI history (KDIGO 2012 AKI; KDIGO 2024 CKD)
    advance: Follow-up scheduled + patient educated (KDIGO 2012 AKI)