Clinical Commander

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renal.ckd-progression.v1

CKD Progression & Management (G1-G5 + ACR stratified)

nephrologychronicadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Promoted to INTEGRATED 2026-05-22 (shard-4 build campaign): added registry-resolving workups (aki_on_ckd, hyperkalemia, secondary_htn); every evidence.pmid re-sourced and live-verified via PubMed; every regimen RxCUI reverse-looked-up live at RxNav. Four-pillar CKD-progression slowing: max-tolerated RAAS blockade + SGLT2i + non-steroidal MRA (finerenone) + BP target per KDIGO 2021/SPRINT; plus CKD-MBD (phosphate binders, active vitamin D, calcimimetic), anemia (ESA), metabolic acidosis (sodium bicarbonate). PMID anchors (live-verified PubMed 2026-05-22): 38490803 KDIGO 2024 CKD, 33637192 KDIGO 2021 BP-CKD, 32970396 DAPA-CKD, 36331190 EMPA-KIDNEY, 33264825 FIDELIO-DKD, 26551272 SPRINT. Prior fabricated PMIDs removed. RxCUI corrections (reverse-verified at RxNav): calcium carbonate 1897, calcitriol 1894, epoetin alfa 105694, cinacalcet 407990, paricalcitol 73710, sodium bicarbonate 36676, darbepoetin alfa 283838, lanthanum carbonate 234416, sevelamer 214824, finerenone 2562811, semaglutide 1991302 (prior codes invalid or wrong-drug). Sibling routing: neph.ckd.core.v1, renal.diabetic-nephropathy.v1.

Entry points (5)

  • lab_abnormality
    Rising creatinine or declining eGFR on annual screening (KDIGO 2012 CKD)
    rising_cr_or_declining_egfr
  • lab_abnormality
    Persistent albuminuria A2/A3 (UACR ≥30 mg/g for ≥3 mo) (KDIGO 2012 CKD)
    persistent_uacr_a2_a3
  • problem_list
    CKD on problem list (continuation visit)
    ckd_on_problem_list
  • lab_abnormality
    eGFR <60 mL/min/1.73 m² for ≥3 mo (KDIGO 2012 CKD)
    low_egfr_lt_60
  • history
    Risk factors — DM, HTN, family CKD, AKI history, glomerular disease (KDIGO 2012 CKD)
    risk_factors_ckd

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Age informs eGFR formula + transplant candidacy + treatment intensity (KDIGO 2012 CKD)
  • creatininerequired
    lab • used at CONTEXT
    Core eGFR input — KDIGO staging G1-G5 (KDIGO 2012 CKD; KDIGO 2024 race-free eGFR)
  • uacrrequired
    lab • used at CONTEXT
    Albuminuria sub-staging A1/A2/A3 + KDIGO heat-map risk (KDIGO 2012 CKD)
  • potassiumrequired
    lab • used at CONTEXT
    RAS + spironolactone + finerenone tolerability (KDIGO 2024)
  • phosphate
    lab • used at INITIAL_WORKUP
    CKD-MBD — phosphate target <5.5 (KDIGO CKD-MBD 2017)
  • ipth
    lab • used at INITIAL_WORKUP
    CKD-MBD — sHPT diagnosis + monitoring (KDIGO CKD-MBD 2017)
  • calcium
    lab • used at INITIAL_WORKUP
    CKD-MBD — calcium target (KDIGO CKD-MBD 2017)
  • hemoglobin
    lab • used at INITIAL_WORKUP
    Anemia of CKD — Hgb <10 + iron-replete → ESA (KDIGO 2012 anemia)
  • bicarbonate
    lab • used at INITIAL_WORKUP
    Metabolic acidosis — HCO3 <22 → sodium bicarbonate (KDIGO 2012 CKD)
  • sbprequired
    vital • used at CONTEXT
    BP target <130/80 (or <120/70 SPRINT) (KDIGO 2012 CKD; AHA 2017)
  • ckd_etiologyrequired
    history • used at CONTEXT
    Cause matters — DKD, HTN, GN, PKD, obstructive each have specific Rx (KDIGO 2012 CKD)
  • current_meds_ras_sglt2i_diureticrequired
    medication • used at CONTEXT
    Med reconciliation; nephrotoxin avoidance; tier ladder (KDIGO 2012 CKD)

12-phase flow (12)

  1. 1FRAME
    KDIGO heat-map stage (G × A) + etiology + complications (CKD-MBD, anemia, acidosis) (KDIGO 2012 CKD)
    inputs: creatinine, uacr, ckd_etiology
    advance: KDIGO stage + etiology + complications documented (KDIGO 2012 CKD)
  2. 2ENTRY
    Triggered by annual screening, rising Cr, persistent A2/A3, low eGFR for ≥3 mo, problem-list continuation (KDIGO 2012 CKD)
    advance: Engine routed (KDIGO 2012 CKD)
  3. 3CONTEXT
    Capture age, BP, K+, etiology, current meds, comorbidities (DM, HTN, CV, family history, AKI history) (KDIGO 2012 CKD)
    inputs: age, sbp, potassium, ckd_etiology, current_meds_ras_sglt2i_diuretic
    advance: Context captured (KDIGO 2012 CKD)
  4. 4RED_FLAGS
    Uremic emergencies (AEIOU) / rapid Cr rise / hyperkalemia >6 / refractory acidosis / nephrotic flare (KDIGO 2012 CKD)
    advance: Acuity tier set (KDIGO 2012 CKD)
  5. 5INITIAL_WORKUP
    BMP, UACR, lipid panel, CBC, iPTH, phos, Ca, bicarb, renal US (KDIGO 2012 CKD; KDIGO CKD-MBD 2017)
    inputs: creatinine, uacr, phosphate, ipth, calcium, hemoglobin, bicarbonate
    actions: panel.renal, panel.cbc, panel.lipid
    advance: Initial labs back (KDIGO 2012 CKD)
  6. 6BRANCHING_WORKUP
    Biopsy if atypical or unclear etiology; cause-specific workup (DKD, GN, PKD, obstructive); CKD-MBD bone biopsy in select (KDIGO 2012 CKD; KDIGO CKD-MBD 2017)
    advance: Etiology workup complete (KDIGO 2012 CKD)
  7. 7DIFFERENTIAL
    CKD etiology — DKD / hypertensive nephropathy / GN (IgAN, lupus, FSGS, MN) / PKD / obstructive / chronic AIN / atherosclerotic / amyloid (KDIGO 2012 CKD)
    advance: Differential resolved (KDIGO 2012 CKD)
  8. 8RISK_STRATIFICATION
    KDIGO heat-map (G × A) + KFRE 4-variable risk (Tangri 2016) + cardiovascular risk (KDIGO 2012 CKD; KDIGO 2024)
    inputs: creatinine, uacr, age, sbp
    actions: calc.ckd_epi_2021
    advance: Risk tier documented (KDIGO 2012 CKD)
  9. 9TREATMENT
    Tier 1 RAS + SGLT2i + statin + BP/A1c + lifestyle (foundational); Tier 2 finerenone if diabetic + albuminuric; Tier 3 GLP-1 RA for metabolic; Tier 4 CKD-MBD (phos binder + active vit D + calcimimetic); Tier 5 anemia (ESA + iron) + acidosis (bicarb); Tier 6 transplant + RRT + AVF + palliative-care option at G4-G5 (KDIGO 2012 CKD; KDIGO 2022; KDIGO CKD-MBD 2017)
    inputs: creatinine, uacr, potassium, sbp, phosphate, hemoglobin, bicarbonate
    advance: Tier ladder executed (KDIGO 2012 CKD)
  10. 10DISPOSITION
    Outpatient nephrology primary (referral threshold by KDIGO heat-map); admit for AKI-on-CKD/uremic emergencies/biopsy (KDIGO 2012 CKD)
    advance: Disposition set (KDIGO 2012 CKD)
  11. 11MONITORING
    eGFR + UACR + K+ + phos + iPTH + Hgb + bicarb q3-6 mo (varies by stage); eGFR slope quarterly (KDIGO 2012 CKD)
    inputs: creatinine, uacr, potassium, phosphate, hemoglobin
    actions: panel.renal
    advance: Monitoring schedule live (KDIGO 2012 CKD)
  12. 12FOLLOWUP
    q3-6 mo nephrology; transplant + RRT planning at G4 (eGFR <30); AVF placement 6 mo pre-RRT; pre-RRT immunization + nutrition + psychosocial; conservative-care choice (KDIGO 2012 CKD; KDIGO 2015)
    advance: Long-term plan documented (KDIGO 2012 CKD)