Clinical Commander

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renal.aki.v1

Acute Kidney Injury

nephrologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

Phase C expansion 2026-05-14: companion to neph.aki.core.v1 with broader KDIGO 2012 stage encoding (Stage 1/2/3) + 12 mechanism phenotypes (prerenal/ATN/AIN/glomerular/vascular/postrenal/CI-AKI/HRS/sepsis-AKI/rhabdo-AKI/TLS/cardiorenal) + 5 setting playbooks (home/ed/icu/inpatient/outpatient). Reuses canonical manifest prisma/seed/manifests/neph.aki.core.v1.ts (no duplicate manifest authored). Phenotype routing: RPGN → renal.rpgn.core.v1; HRS-AKI → gi.hepatorenal-syndrome.core.v1; cardiorenal → cardio.acute-hf.core.v1; TLS → heme.tumor-lysis-syndrome.core.v1; CKD baseline reconciliation → neph.ckd.core.v1. Evidence anchored on STARRT-AKI / AKIKI / IDEAL-ICU (early vs delayed RRT trials — no benefit to early start absent AEIOU), SMART/SALT-ED (balanced crystalloid superior), PRESERVE (negative for prophylactic NAC/NaHCO3 for CI-AKI), DOSE (loop diuretic dosing), CONFIRM (terlipressin in HRS). Schema-blocked calculator queue: KDIGO AKI staging calculator (calc.kdigo_aki — not registered), FENa/FEUrea calculators (calc.fena, calc.feurea — not registered), Cairo-Bishop TLS classification, RIFLE staging (legacy). Surfaced as text in required_assessments + severity_triggers until registry expansion (owner: shard-0 clinical-tools-registry maintainer). Terminology: ICD-10 N17.0-N17.9 + N99.0 (post-procedural); SNOMED 14669001 AKI + 25107001 oliguria + 40095003 ATN + 28637003 AIN + 47032000 HRS; LOINC 2160-0 Cr + 49056-5 eGFR + 2888-6 UPCR. Citation remediation 2026-05-22: all 10 evidence PMIDs re-verified live via PubMed; fabricated/mis-attributed codes corrected (STARRT 32325664→32668114, AKIKI 26913820→27181456, IDEAL-ICU 30304886→30304656, CONFIRM 33657293→33657294, Gonzalez AIN 18497849→18185501; removed unrecoverable 26606878). RxCUIs corrected to RxNav-verified codes: lactated_ringers 1807508→847630, sodium_chloride 7407→9863.

Entry points (6)

  • lab_abnormality
    Creatinine rise ≥0.3 mg/dL in 48h OR ≥1.5x baseline in 7d (KDIGO 2012 AKI)
    creatinine_rise
  • lab_abnormality
    Urine output <0.5 mL/kg/h × ≥6h (KDIGO 2012 AKI)
    oliguria
  • symptom
    New anuria or decreased urine output (KDIGO 2012 AKI)
    anuria
  • lab_abnormality
    Hyperkalemia or acidosis on routine BMP (KDIGO 2012 AKI AEIOU)
    hyperkalemia
  • history
    Contrast administration within 48-72h (KDIGO 2012 AKI; PRESERVE Weisbord NEJM 2018)
    recent_contrast
  • problem_list
    AKI on problem list (continuation visit)
    aki

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Drug dosing + RRT candidacy decisions (KDIGO 2012 AKI)
  • creatininerequired
    lab • used at CONTEXT
    KDIGO staging is creatinine trajectory (KDIGO 2012 AKI)
  • baseline_creatininerequired
    lab • used at CONTEXT
    Required to compute Cr ratio for KDIGO stage (KDIGO 2012 AKI)
  • potassiumrequired
    lab • used at RED_FLAGS
    AEIOU dialysis indication; emergent Rx threshold (KDIGO 2012 AKI)
  • bicarbonaterequired
    lab • used at RED_FLAGS
    Severe acidosis (pH<7.1) is AEIOU dialysis indication (KDIGO 2012 AKI)
  • urine_outputrequired
    vital • used at CONTEXT
    KDIGO oliguria criteria + post-obstruction monitoring (KDIGO 2012 AKI)
  • sbprequired
    vital • used at CONTEXT
    Prerenal hypoperfusion screen + sepsis/cardiogenic shock (KDIGO 2012 AKI)
  • current_medsrequired
    medication • used at CONTEXT
    Nephrotoxin review (NSAID/ACEi/ARB/aminoglycoside/contrast/PPI) (KDIGO 2012 AKI)
  • urinalysis
    lab • used at INITIAL_WORKUP
    Sediment analysis branches mechanism (RBC casts vs muddy-brown vs eosinophils) (KDIGO 2012 AKI)
  • urine_sodium
    lab • used at INITIAL_WORKUP
    FENa/FEUrea distinguishes pre-renal from intrinsic ATN (KDIGO 2012 AKI)
  • renal_us
    imaging • used at BRANCHING_WORKUP
    Hydronephrosis → postrenal phenotype (KDIGO 2012 AKI)
  • cirrhosis
    history • used at CONTEXT
    HRS-AKI per ICA 2019 — albumin challenge + terlipressin (AASLD 2023)
  • ckd
    history • used at CONTEXT
    AKI-on-CKD changes baseline + drug dosing (KDIGO 2024 CKD)
  • recent_contrast
    history • used at CONTEXT
    Contrast-associated AKI phenotype (KDIGO 2012 AKI; PRESERVE NEJM 2018)

12-phase flow (12)

  1. 1FRAME
    Confirm AKI by KDIGO 2012 staging (Cr +0.3/48h OR 1.5x/7d OR oliguria); rule out pseudo-AKI (KDIGO 2012 AKI)
    inputs: creatinine, baseline_creatinine
    advance: KDIGO criteria met and not artifactual (KDIGO 2012 AKI)
  2. 2ENTRY
    Recognize triggering Cr rise / oliguria / hyperkalemia / recent contrast (KDIGO 2012 AKI)
    inputs: creatinine, urine_output
    advance: AKI flagged + demographics captured (KDIGO 2012 AKI)
  3. 3CONTEXT
    Capture vitals, baseline kidney function, comorbidities, full med list, recent contrast/sepsis/cirrhosis (KDIGO 2012 AKI; AASLD 2023)
    inputs: sbp, creatinine, baseline_creatinine, potassium, current_meds, cirrhosis, ckd, recent_contrast
    advance: Comorbidity + nephrotoxin review complete (KDIGO 2012 AKI)
  4. 4RED_FLAGS
    Screen AEIOU emergencies: severe hyperK, refractory acidosis, uremic complications, volume overload, anuria, RPGN sediment, bilateral hydronephrosis, alveolar hemorrhage, tumor lysis (KDIGO 2012 AKI)
    inputs: potassium, bicarbonate, urine_output
    actions: protocol.hyperkalemia
    advance: No AEIOU emergency or routed to RRT/protocol (KDIGO 2012 AKI)
  5. 5INITIAL_WORKUP
    BMP serial Cr, urinalysis with microscopy, FENa/FEUrea, UPCR, CBC, lactate if septic, CK if rhabdo suspected (KDIGO 2012 AKI)
    inputs: urinalysis, urine_sodium
    actions: panel.renal, panel.cbc
    advance: Mechanism class (pre/intrinsic/post) provisional (KDIGO 2012 AKI)
  6. 6BRANCHING_WORKUP
    Renal US for obstruction; urine micro for casts; ANCA/anti-GBM/complement if GN; CK if rhabdo; biopsy if unclear; tumor lysis labs (K/Phos/uric/Ca) (KDIGO 2012 AKI)
    inputs: renal_us
    actions: workup.aki, workup.aki_on_ckd
    advance: Phenotype assigned (prerenal/ATN/AIN/GN/postrenal/HRS/sepsis/rhabdo/TLS/cardiorenal) (KDIGO 2012 AKI)
  7. 7DIFFERENTIAL
    Phenotype: prerenal / ATN / AIN / glomerular (→ renal.rpgn) / vascular / postrenal / CI-AKI / HRS-AKI / sepsis-AKI / rhabdo-AKI / TLS / cardiorenal (KDIGO 2012 AKI)
    advance: Phenotype documented (KDIGO 2012 AKI)
  8. 8RISK_STRATIFICATION
    KDIGO stage 1/2/3 by Cr ratio or urine output; identify AEIOU dialysis indications; predict AKD/CKD progression (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
    inputs: creatinine, baseline_creatinine
    actions: calc.ckd_epi_2021
    advance: Stage + AEIOU status documented (KDIGO 2012 AKI)
  9. 9TREATMENT
    KDIGO bundle: stop nephrotoxins, balanced crystalloid resuscitation (SMART/PLUS), avoid prophylactic NAC (PRESERVE-negative), phenotype-specific Rx, RRT if AEIOU per STARRT-AKI/AKIKI (KDIGO 2012 AKI; STARRT-AKI NEJM 2020; AKIKI NEJM 2016; PRESERVE NEJM 2018)
    inputs: potassium, bicarbonate, sbp
    actions: protocol.hyperkalemia
    advance: Phenotype-specific plan executed; RRT initiated if AEIOU (KDIGO 2012 AKI)
  10. 10DISPOSITION
    ICU for severe AEIOU; nephrology consult stage 2-3 or unclear etiology; urology for obstruction; hepatology for HRS (KDIGO 2012 AKI)
    advance: Disposition + consults set (KDIGO 2012 AKI)
  11. 11MONITORING
    Daily Cr until stable, strict I/O, daily weight, K + acid-base q6-12h while titrating, drug-level adjustment, glycemic 140-180 mg/dL ICU (KDIGO 2012 AKI)
    inputs: creatinine, potassium, urine_output
    actions: panel.renal
    advance: Monitoring orders documented (KDIGO 2012 AKI)
  12. 12FOLLOWUP
    Recheck Cr 1 week post-discharge; nephrology outpatient; 3-month reassessment for CKD progression; med-rec post-AKI; recurrent AKI risk modification (KDIGO 2012 AKI; KDIGO 2024 CKD)
    advance: Follow-up scheduled and patient educated (KDIGO 2012 AKI)