Clinical Commander

All dossiers
renal.diabetic-nephropathy.v1

Diabetic Kidney Disease (DKD)

nephrologychronicadultoutpatientinpatient
Start encounter →Print handoutPRODUCTION

Promoted to INTEGRATED 2026-05-22 (shard-4 build campaign): added registry-resolving workups (aki_on_ckd, hyperkalemia); every evidence.pmid re-sourced and live-verified via PubMed; every regimen RxCUI reverse-looked-up live at RxNav. Diabetic kidney disease pillars (KDIGO 2022 Diabetes in CKD): RAAS blockade (RENAAL/IDNT) + SGLT2i (CREDENCE/DAPA-CKD) + non-steroidal MRA finerenone (FIDELIO/FIGARO-DKD) + GLP-1 RA (FLOW/LEADER) + glycemic/BP/lipid control. PMID anchors (live-verified PubMed 2026-05-22): 36272764 KDIGO 2022 Diabetes-CKD, 11565518 RENAAL, 11565517 IDNT, 30990260 CREDENCE, 33264825 FIDELIO-DKD, 34449181 FIGARO-DKD, 38785209 FLOW, 32970396 DAPA-CKD, 27295427 LEADER. Prior fabricated PMIDs removed. RxCUI corrections (reverse-verified at RxNav): finerenone 2562811, semaglutide 1991302 (prior 2549920 / 1991306 were an invalid concept / a packaged product). Sibling routing: neph.ckd.core.v1, renal.ckd-progression.v1, endo.dm2.core.v1.

Entry points (5)

  • lab_abnormality
    Rising UACR ≥30 mg/g in patient with diabetes (KDIGO 2022 Diabetes-in-CKD)
    rising_uacr_in_dm
  • lab_abnormality
    Declining eGFR + diabetes (KDIGO 2022 Diabetes-in-CKD)
    declining_egfr_in_dm
  • problem_list
    Diabetic kidney disease on problem list (KDIGO 2022)
    dkd_on_problem_list
  • lab_abnormality
    Atypical features (rapid Cr rise, hematuria + RBC casts, low complement, no retinopathy) → biopsy NDD (KDIGO 2022)
    atypical_aki_in_dm
  • problem_list
    Type 1 or Type 2 diabetes — annual UACR + eGFR screening (KDIGO 2022)
    dm1_or_dm2

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    A1c target individualization + transplant candidacy + treatment intensity (KDIGO 2022 Diabetes-in-CKD)
  • dm_type_t1_or_t2required
    history • used at CONTEXT
    T1DM vs T2DM drives drug class eligibility (e.g., GLP-1 RA primarily T2DM) (KDIGO 2022)
  • dm_durationrequired
    history • used at CONTEXT
    Long duration + classic albuminuria pattern supports DKD; short duration + atypical → biopsy NDD (KDIGO 2022)
  • creatininerequired
    lab • used at CONTEXT
    eGFR + CKD staging core to KDIGO heat-map (KDIGO 2022)
  • uacrrequired
    lab • used at CONTEXT
    Albuminuria stage A1/A2/A3 drives therapy escalation (KDIGO 2022)
  • a1crequired
    lab • used at CONTEXT
    Glycemic control target individualized (<7% young, <8% elderly/frail) (KDIGO 2022)
  • potassiumrequired
    lab • used at CONTEXT
    RAS + finerenone tolerability + spironolactone safety (FIDELIO 2020)
  • sbprequired
    vital • used at CONTEXT
    BP target <130/80 (consider <120/70 SPRINT-extension) (KDIGO 2022)
  • retinopathy_present
    history • used at RISK_STRATIFICATION
    Retinopathy correlates with classic DKD; absence with long DM duration → atypical → biopsy NDD (KDIGO 2022)
  • ascvd_present
    history • used at CONTEXT
    Routes cardio.ascvd.chronic.v1 for primary/secondary prevention overlay (ACC/AHA Lipid 2026)
  • pregnancy_or_planning
    history • used at CONTEXT
    Pregnancy → discontinue ACEi/ARB/SGLT2i/finerenone; switch to nifedipine + labetalol + insulin (KDIGO 2022)
  • current_meds_acei_arb_sglt2i_finerenone_glp1required
    medication • used at CONTEXT
    Med reconciliation for tier ladder; finerenone + spironolactone K+ stacking (FIDELIO 2020)

12-phase flow (12)

  1. 1FRAME
    Confirm DKD via DM + albuminuria/eGFR-decline + retinopathy support; classify KDIGO heat-map stage (KDIGO 2022 Diabetes-in-CKD)
    inputs: creatinine, uacr, a1c
    advance: DKD framework established (KDIGO 2022)
  2. 2ENTRY
    Triggered by annual UACR + eGFR screening in DM, rising Cr, atypical features prompting biopsy (KDIGO 2022)
    advance: Engine routed (KDIGO 2022)
  3. 3CONTEXT
    Capture DM type + duration, A1c, BP, K+, retinopathy, ASCVD, pregnancy planning, current meds (KDIGO 2022)
    inputs: age, dm_type_t1_or_t2, dm_duration, a1c, potassium, sbp, retinopathy_present, ascvd_present, pregnancy_or_planning, current_meds_acei_arb_sglt2i_finerenone_glp1
    advance: Context captured (KDIGO 2022)
  4. 4RED_FLAGS
    Rapid Cr rise / hematuria + RBC casts / nephrotic-range proteinuria / pulmonary-renal — atypical features prompting biopsy NDD (KDIGO 2022)
    advance: Atypical phenotype routed for biopsy OR classic DKD continued (KDIGO 2022)
  5. 5INITIAL_WORKUP
    BMP, UACR, A1c, lipid panel, fundoscopic eval, renal US, complement + ANA if atypical (KDIGO 2022)
    inputs: creatinine, uacr, a1c
    actions: panel.renal, panel.lipid
    advance: Initial labs back + fundoscopic done (KDIGO 2022)
  6. 6BRANCHING_WORKUP
    Biopsy if atypical (NDD suspected); ophthalmology referral; ASCVD evaluation per Lipid 2026 (KDIGO 2022; Lipid 2026)
    advance: Atypical workup complete OR classic DKD confirmed (KDIGO 2022)
  7. 7DIFFERENTIAL
    Classic DKD (albuminuric) / non-albuminuric DKD / biopsy-discordant NDD / overlap with HTN / GN / amyloid (KDIGO 2022)
    advance: Differential resolved (KDIGO 2022)
  8. 8RISK_STRATIFICATION
    KDIGO heat-map (eGFR × ACR) + KFRE 4-variable + ASCVD risk + retinopathy stage (KDIGO 2022)
    inputs: creatinine, uacr, sbp, age, retinopathy_present
    actions: calc.ckd_epi_2021
    advance: Risk tier documented (KDIGO 2022)
  9. 9TREATMENT
    Tier 1 foundation (max RAS + SGLT2i + statin + BP <130/80 + A1c individualized + lifestyle); Tier 2 add finerenone if residual albuminuria + eGFR ≥25 + K+ ≤4.8 (FIDELIO 2020 + FIGARO 2021); Tier 3 GLP-1 RA for metabolic + CV/renal (LEADER 2016; FLOW 2024); Tier 4 transplant/RRT planning at G4-5 (KDIGO 2022)
    inputs: uacr, creatinine, a1c, potassium, sbp
    advance: Tier ladder executed + tolerability documented (KDIGO 2022)
  10. 10DISPOSITION
    Outpatient nephrology + endocrinology + ophthalmology + cardiology co-management primary; admit for AKI/nephrotic flare/biopsy (KDIGO 2022)
    advance: Disposition set (KDIGO 2022)
  11. 11MONITORING
    UACR + eGFR + K+ + BP + A1c q3-6 mo; nephrology q3-6 mo; ophthalmology annually (KDIGO 2022)
    inputs: creatinine, uacr, a1c, potassium, sbp
    actions: panel.renal
    advance: Monitoring schedule live (KDIGO 2022)
  12. 12FOLLOWUP
    q3-6 mo nephrology + endocrinology; transplant evaluation at G4 (eGFR <30); AVF placement 6 mo pre-RRT; pre-RRT immunization + nutrition + psychosocial (KDIGO 2022)
    advance: Long-term plan documented (KDIGO 2022)