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renal.aki.prerenal.v1

Acute Kidney Injury — Pre-renal Mechanism

nephrologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C wave-7 2026-05-15: mechanism-specific deep-dive carved from renal.aki.v1; covers volume-depletion / third-spacing / cardiorenal types 1-2 / HRS-AKI per ICA 2019 / NSAID-induced / ACEi-ARB-induced / bilateral RAS on ACEi / abdominal compartment syndrome. Diagnostic pivot: FeNa <1% + BUN:Cr >20:1 + urine osm >500 + hyaline casts + Cr response to volume challenge (Carvounis Kidney Int 2002 PMID 12427149). Phenotype routing: HRS-AKI → gi.hepatorenal-syndrome.core.v1 (CONFIRM Wong NEJM 2021 PMID 33657294 — terlipressin FDA approved 2022); cardiorenal type 1 → cardio.acute-hf.core.v1 (DOSE NEJM 2011 PMID 21366472); cardiogenic shock → cardio.cardiogenic-shock.core.v1; sustained hypoperfusion → renal.aki.intrinsic.atn.v1; parent all-cause → renal.aki.v1. Evidence anchored on KDIGO 2012 AKI + ICA 2019 HRS-AKI consensus + AASLD 2023 + SMART/SALT-ED 2018 (balanced crystalloid superior) + BaSICS 2021 + PLUS 2022 (mixed) + CONFIRM 2021 (terlipressin) + DOSE 2011 (loop diuretic). Schema-blocked calculator queue: FeNa / FeUrea / Mehta-Cockroft-Gault for HRS staging — 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.prerenal.v1.ts; full seed manifest deferred to a later terminology-completion pass. INTEGRATED tier: regimen axis prerenal_volume_perfusion with 5 steps + 5 settings + 11 severity triggers + 5 sibling differentiations + 14 evidence PMIDs + dedicated test file. Citation + RxCUI remediation 2026-05-22: every evidence PMID re-verified live via PubMed (fabricated/mis-attributed codes corrected — ICA 31010807→25638527 Angeli 2015, CONFIRM 33657293→33657294, STARRT 32325664→32668114, Carvounis 12393929→12427149; removed unrecoverable 32101160/30094008/25950707-Ronco/28049694-NSAID). RxCUIs corrected to RxNav-verified codes: lactated_ringers 1807508→847630, sodium_chloride 7407→9863, albumin_25% 519→828529, midodrine 7042→6963, octreotide 40790→7617, nitroglycerin 1191→4917.

Entry points (6)

  • lab_abnormality
    Creatinine rise with FeNa <1% + BUN:Cr >20 (KDIGO 2012 AKI; Carvounis Kidney Int 2002)
    creatinine_rise_prerenal
  • lab_abnormality
    Oliguria + dehydration / volume loss / GI losses (KDIGO 2012 AKI)
    oliguria_dehydration
  • symptom
    Vomiting / diarrhea / hemorrhage / diuretic overuse (KDIGO 2012 AKI)
    vomiting_diarrhea
  • history
    Cirrhosis with AKI not responsive to albumin challenge — HRS-AKI suspicion (AASLD 2023; ICA 2019)
    cirrhosis_hrs
  • history
    Acute HF with worsening renal function — cardiorenal type 1 (KDIGO 2012 AKI; AHA/ACC HF 2022)
    acute_hf_cardiorenal
  • medication
    Active NSAID / ACEi / ARB use with new Cr rise (KDIGO 2012 AKI)
    nsaid_acei_arb_exposure

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Volume resuscitation tolerance + drug dosing (KDIGO 2012 AKI)
  • creatininerequired
    lab • used at CONTEXT
    KDIGO staging + Cr response to volume challenge (KDIGO 2012 AKI)
  • baseline_creatininerequired
    lab • used at CONTEXT
    Required to compute Cr ratio for KDIGO stage + judge recovery (KDIGO 2012 AKI)
  • bunrequired
    lab • used at INITIAL_WORKUP
    BUN:Cr ratio >20:1 supports pre-renal mechanism (KDIGO 2012 AKI; Carvounis 2002)
  • urine_sodium
    lab • used at INITIAL_WORKUP
    FeNa <1% supports pre-renal (KDIGO 2012 AKI; Carvounis 2002)
  • urine_osmolality
    lab • used at INITIAL_WORKUP
    Urine osm >500 supports concentrating ability + pre-renal (KDIGO 2012 AKI)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Hyaline casts (pre-renal); rule out muddy-brown ATN, RBC casts GN (KDIGO 2012 AKI)
  • sbprequired
    vital • used at CONTEXT
    Hypoperfusion screen — distributive vs hypovolemic vs cardiogenic shock (KDIGO 2012 AKI; SSC 2026)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia supports hypovolemia (KDIGO 2012 AKI)
  • urine_outputrequired
    vital • used at CONTEXT
    Oliguria criteria + monitoring response (KDIGO 2012 AKI)
  • current_medsrequired
    medication • used at CONTEXT
    NSAID / ACEi / ARB / diuretic / SGLT2i review (KDIGO 2012 AKI)
  • cirrhosis
    history • used at CONTEXT
    HRS-AKI per ICA 2019 — albumin challenge + terlipressin (AASLD 2023)
  • acute_hf
    history • used at CONTEXT
    Cardiorenal type 1 — diuretic + vasodilator strategy (DOSE NEJM 2011)
  • recent_volume_loss
    history • used at CONTEXT
    Vomiting / diarrhea / hemorrhage / burns / NG suction (KDIGO 2012 AKI)
  • albumin
    lab • used at INITIAL_WORKUP
    Hypoalbuminemia supports third-spacing; HRS workup (AASLD 2023)

12-phase flow (12)

  1. 1FRAME
    Confirm AKI by KDIGO 2012 staging AND mechanism profile suggests pre-renal (FeNa <1%, BUN:Cr >20, urine osm >500, hyaline casts) (KDIGO 2012 AKI; Carvounis 2002)
    inputs: creatinine, baseline_creatinine
    advance: KDIGO criteria met + pre-renal profile (KDIGO 2012 AKI)
  2. 2ENTRY
    Cr rise + clinical context of volume loss / third-spacing / HF / cirrhosis / NSAID-ACEi exposure (KDIGO 2012 AKI)
    inputs: creatinine, urine_output
    advance: Pre-renal phenotype suspected (KDIGO 2012 AKI)
  3. 3CONTEXT
    Volume status assessment (skin turgor, JVP, lungs, edema, weight delta); med review (NSAID, ACEi/ARB, diuretic, SGLT2i); recent contrast/sepsis/cirrhosis (KDIGO 2012 AKI; AASLD 2023)
    inputs: sbp, hr, current_meds, cirrhosis, acute_hf, recent_volume_loss
    advance: Volume context + nephrotoxin review complete (KDIGO 2012 AKI)
  4. 4RED_FLAGS
    Hemorrhagic shock; septic shock + hypoperfusion; cardiogenic shock; abdominal compartment syndrome (IAP >20 + organ dysfunction); HRS-AKI requiring terlipressin (KDIGO 2012 AKI; SSC 2026; AASLD 2023)
    inputs: sbp, hr
    advance: Shock screen complete + ACS measurement if suspected (KDIGO 2012 AKI)
  5. 5INITIAL_WORKUP
    BMP, BUN:Cr ratio, FeNa, FeUrea (if diuretic on board), urine osm, urinalysis with microscopy, lactate (if septic), albumin (KDIGO 2012 AKI; Carvounis 2002)
    inputs: urinalysis, urine_sodium, urine_osmolality, bun, albumin
    actions: panel.renal, panel.cbc
    advance: Pre-renal vs ATN distinction made (KDIGO 2012 AKI)
  6. 6BRANCHING_WORKUP
    Echocardiography if cardiorenal; abdominal US for cirrhosis + ascites; bladder pressure if abdominal compartment syndrome suspected; SBP fluid analysis if cirrhosis + AKI (KDIGO 2012 AKI; AASLD 2023)
    advance: Pre-renal sub-phenotype identified (KDIGO 2012 AKI; AASLD 2023)
  7. 7DIFFERENTIAL
    Pre-renal sub-phenotypes: volume-depletion / third-spacing / cardiorenal type 1 / cardiorenal type 2 / HRS-AKI / NSAID-induced / ACEi-ARB-induced / RAS-on-ACEi / abdominal compartment syndrome (KDIGO 2012 AKI; AASLD 2023; ICA 2019)
    advance: Sub-phenotype documented (KDIGO 2012 AKI)
  8. 8RISK_STRATIFICATION
    KDIGO stage 1/2/3; identify HRS-AKI (vs simple pre-renal) by albumin trial; risk of progression to ATN if hypoperfusion sustained (KDIGO 2012 AKI; ICA 2019)
    inputs: creatinine
    actions: calc.ckd_epi_2021
    advance: Stage + sub-phenotype severity documented (KDIGO 2012 AKI)
  9. 9TREATMENT
    Volume resuscitation with balanced crystalloid (SMART/SALT-ED) — LR/Plasmalyte preferred; albumin 1 g/kg challenge for cirrhosis (AASLD 2023); terlipressin + albumin for HRS-AKI (CONFIRM NEJM 2021); discontinue NSAID/ACEi/ARB transiently; treat underlying (sepsis, GI bleed, HF); RRT only if AEIOU met (KDIGO 2012 AKI; SMART NEJM 2018; CONFIRM NEJM 2021)
    inputs: sbp, urine_output
    advance: Phenotype-specific plan executed (KDIGO 2012 AKI)
  10. 10DISPOSITION
    ICU for HRS-AKI on terlipressin / shock / refractory AEIOU; ward for stable resuscitation; outpatient for mild reversible cause (KDIGO 2012 AKI; AASLD 2023)
    advance: Disposition + consults set (KDIGO 2012 AKI)
  11. 11MONITORING
    Cr q12-24h until improvement, strict I/O, daily weight, MAP target, electrolytes (post-resuscitation hyperchloremic acidosis with NS), albumin level if HRS protocol (KDIGO 2012 AKI; SMART NEJM 2018; AASLD 2023)
    inputs: creatinine, urine_output
    actions: panel.renal
    advance: Monitoring orders + Cr trajectory documented (KDIGO 2012 AKI)
  12. 12FOLLOWUP
    Re-introduce ACEi/ARB cautiously post-recovery (KDIGO 2024 CKD); permanent NSAID avoidance; sick-day med-rec for diuretic/SGLT2i/ACEi during AGE; hepatology follow-up for cirrhosis; cardiology for HF (KDIGO 2012 AKI; KDIGO 2024 CKD; AASLD 2023)
    advance: Follow-up scheduled + patient educated (KDIGO 2012 AKI)