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neph.aki.core.v1PRODUCTION
neph.aki.core.v1

Acute Kidney Injury (KDIGO)

nephrologyacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm AKI by KDIGO criteria (Cr +0.3/48h or 1.5x/7d or oliguria) and exclude pseudoAKI

Inputs
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Actions
0
Advance rule
Set
Advance when

KDIGO criteria met and not artifactual

Patient inputs (14)

Drug dosing + biopsy candidacy + RRT decisions (KDIGO 2012)

KDIGO staging is creatinine trajectory (KDIGO 2012)

Required to calculate Cr ratio for KDIGO stage (KDIGO 2012)

KDIGO oliguria criteria + post-obstruction monitoring (KDIGO 2012)

Pre-renal hypoperfusion screen + sepsis/cardiogenic shock (KDIGO 2012)

Nephrotoxin review (NSAID/ACEi/ARB/aminoglycoside/contrast/PPI) (KDIGO 2012)

Hyperkalemia is AEIOU dialysis indication; emergency Rx threshold (KDIGO 2012)

Severe acidosis (pH<7.1) is AEIOU dialysis indication (KDIGO 2012)

Hydronephrosis → postrenal phenotype (KDIGO 2012)

HRS-AKI requires albumin challenge + terlipressin (AASLD 2023)

AKI-on-CKD changes baseline + drug dosing (KDIGO 2024)

Contrast-associated AKI vs other ATN (KDIGO 2012)

Sediment analysis branches mechanism (casts, RBC, WBC, eos) (KDIGO 2012)

FENa/FEUrea distinguishes pre-renal from intrinsic ATN (KDIGO 2012)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningaeiou_acidosis_refractory (KDIGO 2012)
    pH <7.1 OR HCO3 <10 not responsive to bicarbonate infusion (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaeiou_hyperkalemia_refractory (KDIGO 2012)
    K >6.5 OR ECG changes despite shift therapy + binder (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaeiou_intoxication (KDIGO 2012; EXTRIP)
    Lithium / salicylate / methanol / ethylene glycol / metformin lactic acidosis with severe AKI (KDIGO 2012; EXTRIP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaeiou_overload (KDIGO 2012)
    Pulmonary edema not responsive to high-dose IV loop diuretic (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaeiou_uremia (KDIGO 2012)
    Uremic encephalopathy / pericarditis / bleeding diathesis with BUN >100 (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererpgn_pattern (KDIGO 2012)
    RBC casts + dysmorphic RBCs + falling eGFR + proteinuria (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehrs_aki_pattern (AASLD 2023)
    Cirrhosis + AKI not responsive to 48h albumin challenge + no shock/nephrotoxin (AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateoliguria_persistent (KDIGO 2012)
    Urine output <0.5 mL/kg/h x 6h despite resuscitation (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

AKI phenotype-driven management (KDIGO 2012/2026)
axis: aki_phenotype_stepwisestep prerenal - Prerenal AKI — volume depletion / true hypovolemia
Selected step "Prerenal AKI — volume depletion / true hypovolemia" — FENa <1%, BUN/Cr >20, urine osm >500, history of GI losses / hemorrhage / hypotension
  • lactated_ringers
    first line
    balanced_crystalloid
    10-20 mL/kg bolus • IV • titrate to MAP >65 + UOP >0.5 mL/kg/h
    triggers: prerenal, true_volume_depletion
    KDIGO 2026 + SMART/PLUS — balanced crystalloid preferred over saline to avoid hyperchloremic acidosis
    rxcui 847630
  • sodium_chloride_0.9%
    second line
    crystalloid
    10-20 mL/kg bolus • IV • titrate
    triggers: hypochloremic_alkalosis, no_balanced_crystalloid
    Acceptable when balanced crystalloid unavailable
    rxcui 9863

ed playbook — drug actions (5)

  1. 1. calcium gluconate
    1 g IV (10 mL of 10%) over 5 min • IV • repeat q5-10 min if ECG persists
    trigger: K ≥6.5 OR ECG changes
    Membrane stabilization; UK Renal Association 2023
  2. 2. insulin + dextrose
    10 U regular insulin IV + 25 g D50 • IV • check glucose q1h × 4
    trigger: K ≥6.0
    Cellular K shift (Cochrane 2015)
  3. 3. albuterol nebulized
    10-20 mg nebulized • inhaled • single dose
    trigger: K ≥6.0 + no severe tachycardia
    Additive shift therapy
  4. 4. lactated ringers bolus
    500-1000 mL over 30 min, reassess • IV • titrate to MAP/UOP
    trigger: Prerenal pattern + hypotension
    KDIGO 2026 balanced crystalloid
  5. 5. furosemide
    40-80 mg IV • IV • single dose then reassess
    trigger: Volume overload OR cardiorenal
    Volume management only

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Creatinine rise ≥0.3 in 48h or ≥1.5x baseline in 7d (KDIGO 2012); Oliguria <0.5 mL/kg/h ≥6h (KDIGO 2012); Anuria / decreased urine output (KDIGO 2012).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Kidney Injury (KDIGO)** (neph.aki.core.v1).
Phenotype framing: Phenotype: prerenal / ATN / AIN / GN (→ renal.rpgn) / postrenal / HRS-AKI / cardiorenal / TMA
Scope: Confirm AKI by KDIGO criteria (Cr +0.3/48h or 1.5x/7d or oliguria) and exclude pseudoAKI

No severity triggers fired against current inputs.

Plan

Regimen axis: **AKI phenotype-driven management (KDIGO 2012/2026)** — step "Prerenal AKI — volume depletion / true hypovolemia".
1. lactated_ringers 10-20 mL/kg bolus IV titrate to MAP >65 + UOP >0.5 mL/kg/h (balanced_crystalloid, first line) — KDIGO 2026 + SMART/PLUS — balanced crystalloid preferred over saline to avoid hyperchloremic acidosis
2. sodium_chloride_0.9% 10-20 mL/kg bolus IV titrate (crystalloid, second line) — Acceptable when balanced crystalloid unavailable

Setting playbook (ed) — Identify AEIOU emergencies, initiate phenotype-specific resuscitation, decide ward vs ICU vs RRT (KDIGO 2012)
3. calcium gluconate 1 g IV (10 mL of 10%) over 5 min IV repeat q5-10 min if ECG persists — K ≥6.5 OR ECG changes (Membrane stabilization; UK Renal Association 2023)
4. insulin + dextrose 10 U regular insulin IV + 25 g D50 IV check glucose q1h × 4 — K ≥6.0 (Cellular K shift (Cochrane 2015))
5. albuterol nebulized 10-20 mg nebulized inhaled single dose — K ≥6.0 + no severe tachycardia (Additive shift therapy)
6. lactated ringers bolus 500-1000 mL over 30 min, reassess IV titrate to MAP/UOP — Prerenal pattern + hypotension (KDIGO 2026 balanced crystalloid)
7. furosemide 40-80 mg IV IV single dose then reassess — Volume overload OR cardiorenal (Volume management only)

Non-pharmacologic actions:
- Stop all nephrotoxins (NSAID, ACEi, ARB, aminoglycoside, contrast, recent metformin) (KDIGO 2012)
- Foley catheter if obstruction suspected or for strict UOP measurement (KDIGO 2012)
- Renal US within 6 h if anuria or no clear etiology (KDIGO 2012)
- STAT nephrology consult if RPGN, severe AEIOU, or unclear etiology (KDIGO 2012)

AVOID / contraindication checks:
- Loop diuretic monitor K and Mg (KDIGO 2012)
- Terlipressin block if active cv ischemia (AASLD 2023)
- Albumin caution if volume overloaded (KDIGO 2012)
- Nsaid acei arb hold in AKI (KDIGO 2012)
- Contrast avoid or minimize dose (KDIGO 2012)
- Aminoglycoside once daily and trough (KDIGO 2012)

Monitoring

Regimen monitoring:
- BMP q24h during acute phase (KDIGO 2012)
- urine output hourly (KDIGO 2012)
- daily weight (KDIGO 2012)
- MAP hourly if HRS or pressors (AASLD 2023)
- lactate q12h if septic (SSC 2021)

Setting (ed) monitoring:
- BMP q4-6h until K + Cr stabilize (KDIGO 2012)
- Urine output hourly (KDIGO 2012)
- Continuous ECG if K ≥6.0 (KDIGO 2012)
- MAP q15 min during resuscitation (KDIGO 2012)

Follow-up plan: Recheck Cr 1 week post-discharge; nephrology outpatient; 3-month reassessment for CKD progression; med-rec post-AKI
- Close-out criterion: Follow-up scheduled and patient educated

Monitoring phase: Daily Cr until stable, strict I/O, daily weight, K + acid-base q6-12h while titrating, drug-level adjustment

Disposition

Current setting: ed — Identify AEIOU emergencies, initiate phenotype-specific resuscitation, decide ward vs ICU vs RRT (KDIGO 2012)

Disposition criteria:
- Discharge: KDIGO stage 1, clear reversible cause (e.g., mild dehydration), Cr trending down, no AEIOU, follow-up within 48-72h (KDIGO 2012)
- Admit ward: KDIGO stage 1-2 needing IV fluids/observation, no AEIOU, stable K (KDIGO 2012)
- Admit ICU: KDIGO stage 3, AEIOU criteria, hemodynamic instability, RRT-imminent (KDIGO 2012)

Escalation triggers (move to higher acuity):
- Refractory K ≥6.5 despite shift therapy → ICU + dialysis prep (KDIGO 2012 AEIOU)
- pH <7.1 not responsive to bicarb → ICU + dialysis (KDIGO 2012 AEIOU)
- Anuria + volume overload → ICU + RRT (KDIGO 2012 AEIOU)
- Pulmonary-renal syndrome → ICU + nephrology + rheumatology (KDIGO 2012)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] pH <7.1 OR HCO3 <10 not responsive to bicarbonate infusion (KDIGO 2012)
- [LIFE_THREATENING] K >6.5 OR ECG changes despite shift therapy + binder (KDIGO 2012)
- [LIFE_THREATENING] Lithium / salicylate / methanol / ethylene glycol / metformin lactic acidosis with severe AKI (KDIGO 2012; EXTRIP)

Citations

- KDIGO 2026 AKI/AKD Draft (public review through April 2026; https://kdigo.org/guidelines/acute-kidney-injury/) + KDIGO 2012 AKI Guideline (binding) + SSC 2026 (initial resuscitation) + AASLD 2023 ACLF (HRS-AKI) + CONFIRM NEJM 2021 (terlipressin) + DOSE NEJM 2011 (loop diuretic dosing) + SMART/PLUS (balanced crystalloid) + STARRT-AKI / AKIKI (early vs delayed RRT) [PMID:22890468](https://pubmed.ncbi.nlm.nih.gov/22890468/)
- Cited evidence (PMID 30304656) [PMID:30304656](https://pubmed.ncbi.nlm.nih.gov/30304656/)
- Cited evidence (PMID 33657294) [PMID:33657294](https://pubmed.ncbi.nlm.nih.gov/33657294/)
- Cited evidence (PMID 21366472) [PMID:21366472](https://pubmed.ncbi.nlm.nih.gov/21366472/)
- Cited evidence (PMID 29485925) [PMID:29485925](https://pubmed.ncbi.nlm.nih.gov/29485925/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2026 AKI/AKD Draft (public review through April 2026; https://kdigo.org/guidelines/acute-kidney-injury/) + KDIGO 2012 AKI Guideline (binding) + SSC 2026 (initial resuscitation) + AASLD 2023 ACLF (HRS-AKI) + CONFIRM NEJM 2021 (terlipressin) + DOSE NEJM 2011 (loop diuretic dosing) + SMART/PLUS (balanced crystalloid) + STARRT-AKI / AKIKI (early vs delayed RRT) — PMID:22890468
  • Cited evidence (PMID 30304656) — PMID:30304656
  • Cited evidence (PMID 33657294) — PMID:33657294
  • Cited evidence (PMID 21366472) — PMID:21366472
  • Cited evidence (PMID 29485925) — PMID:29485925