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neph.ckd.core.v1PRODUCTION
neph.ckd.core.v1

Chronic Kidney Disease (KDIGO G/A staging + GDMT)

nephrologychronicadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm CKD: eGFR <60 OR UACR ≥30 OR structural marker, sustained ≥3 months (KDIGO 2024)

Inputs
2
Actions
0
Advance rule
Set
Advance when

KDIGO 2024 chronicity criteria met (not acute injury)

Patient inputs (13)

eGFR + KFRE risk (Tangri JAMA 2016) + statin eligibility ages 50–79 (SHARP, Baigent Lancet 2011)

CKD-EPI 2021 race-free eGFR — KDIGO 2024 staging foundation

KDIGO 2024 A1/A2/A3 albuminuria stage; gates SGLT2i + finerenone

KDIGO 2024 BP target SBP <120 if tolerated; gates RAS titration

RAS + finerenone + MRA gating; baseline before titration (KDIGO 2024)

DKD = primary indication for SGLT2i (DAPA-CKD, Heerspink NEJM 2020) + finerenone (FIDELIO-DKD, Bakris NEJM 2020) + GLP-1 (FLOW)

Detect existing RAS/SGLT2i; flag NSAIDs, contrast risk (KDIGO 2024)

Statin + ASCVD risk assessment (SHARP, Baigent Lancet 2011)

DM control gates GLP-1 (FLOW NEJM 2024) + SGLT2i benefit independent of glycemic effect (DAPA-CKD)

CKD-MBD assessment stage 4–5 (KDIGO 2017 CKD-MBD)

CKD-MBD; secondary hyperparathyroidism (KDIGO 2017 CKD-MBD)

Anemia of CKD; iron + ESA threshold (KDIGO 2012 Anemia)

Metabolic acidosis stage 3b–5; oral bicarb target HCO3 22–29 (KDIGO 2024)

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

Severity triggers (6)

6 need judgement
  • informationallife_threateninguremic_emergency
    Uremic pericarditis / encephalopathy / bleeding diathesis (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereeGFR_under_15_initiate_rrt
    eGFR <15 OR uremic symptoms — encephalopathy, pericarditis, anorexia, pruritus (KDIGO 2012)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterapid_progression
    eGFR decline >3 mL/min/yr OR doubling of UACR (KDIGO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehyperK_on_ras
    K >5.5 on ACEi/ARB/MRA/finerenone (KDIGO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateeGFR_under_30_vascular_access
    eGFR <30 — initiate vascular access education + nephrology referral (KDIGO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesick_day_aki_pattern
    Acute illness (vomiting / diarrhea / sepsis) with rising Cr on RAS+SGLT2i (KDIGO 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

KDIGO G1-G5 stage-driven management (KDIGO 2024)
axis: ckd_kdigo_stagesstep G1 - G1 — eGFR ≥90 with markers of damage — UACR ≥30 or structural (KDIGO 2024)
Selected step "G1 — eGFR ≥90 with markers of damage — UACR ≥30 or structural (KDIGO 2024)" — eGFR ≥90 AND (UACR ≥30 OR imaging marker OR biopsy)
  • lisinopril
    first line
    ACEi
    10 mg PO • PO • daily, titrate to 40 mg
    triggers: UACR>=30, no_acei_intolerance
    KDIGO 2024 proteinuric-CKD foundation. UACR ↓ ~35–40% over wks; expect acute eGFR dip 10–20% then slope flattens. REIN (PMID 9217756): GFR decline 0.53 vs 0.88 mL/min/mo, p=0.03; doubling-Cr/ESRD 18 vs 40 events, p=0.04 (non-diabetic proteinuric CKD)
    rxcui 29046
  • atorvastatin
    add on
    statin
    20 mg PO • PO • daily
    triggers: age_50_79, no_dialysis
    KDIGO 2024 lipid — fixed-dose statin, no LDL target. No eGFR-slope effect; ΔLDL ~−40% in wks. SHARP (PMID 21663949): major atherosclerotic events RR 0.83 (0.74–0.94), p=0.0021 in CKD
    rxcui 83367

outpatient playbook — drug actions (7)

  1. 1. lisinopril/losartan
    Lisinopril 10-40 mg PO daily; losartan 50-100 mg • PO • daily
    trigger: UACR ≥30
    KDIGO 2024 foundation; REIN (Ruggenenti Lancet 1998); titrate to max tolerated
  2. 2. dapagliflozin/empagliflozin
    10 mg PO daily • PO • daily
    trigger: eGFR ≥20
    DAPA-CKD (Heerspink NEJM 2020) / EMPA-KIDNEY (Herrington NEJM 2023)
  3. 3. finerenone
    10 mg PO daily, up to 20 mg • PO • daily
    trigger: DKD + UACR ≥30 + K <5.0 + eGFR ≥25
    FIDELIO-DKD (Bakris NEJM 2020) / FIGARO-DKD (Pitt NEJM 2021)
  4. 4. semaglutide
    0.25 mg SC weekly, titrate to 1-2 mg • SC • weekly
    trigger: DM2 + CKD + not at glycemic target on metformin/SGLT2i
    FLOW (Perkovic NEJM 2024); ADA 2026 §11
  5. 5. atorvastatin
    20-80 mg PO daily • PO • daily
    trigger: Age 50-79 + no dialysis
    SHARP (Baigent Lancet 2011); KDIGO 2013 Lipid
  6. 6. sodium bicarbonate
    650 mg PO BID-TID • PO • BID-TID
    trigger: HCO3 <22
    KDIGO 2024 alkali therapy
  7. 7. erythropoiesis-stimulating agent
    Epoetin 50-100 U/kg SC 3x/week OR darbepoetin 0.45 mcg/kg q2w • SC • 1-3x/week
    trigger: Hb <10 + iron-replete + no contraindication
    KDIGO 2012 Anemia; target Hb 10-11.5

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: eGFR <60 sustained ≥3 months (KDIGO 2024); UACR ≥30 mg/g sustained ≥3 months (KDIGO 2024); Existing CKD on problem list — titration visit (KDIGO 2024).

Objective

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

Assessment

**Chronic Kidney Disease (KDIGO G/A staging + GDMT)** (neph.ckd.core.v1).
Phenotype framing: KDIGO 2024 G/A stage assignment via ckd-staging.service.ts; subtype: DKD / HTN / GN / cystic / ischemic
Scope: Confirm CKD: eGFR <60 OR UACR ≥30 OR structural marker, sustained ≥3 months (KDIGO 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **KDIGO G1-G5 stage-driven management (KDIGO 2024)** — step "G1 — eGFR ≥90 with markers of damage — UACR ≥30 or structural (KDIGO 2024)".
1. lisinopril 10 mg PO PO daily, titrate to 40 mg (ACEi, first line) — KDIGO 2024 proteinuric-CKD foundation. UACR ↓ ~35–40% over wks; expect acute eGFR dip 10–20% then slope flattens. REIN (PMID 9217756): GFR decline 0.53 vs 0.88 mL/min/mo, p=0.03; doubling-Cr/ESRD 18 vs 40 events, p=0.04 (non-diabetic proteinuric CKD)
2. atorvastatin 20 mg PO PO daily (statin, add on) — KDIGO 2024 lipid — fixed-dose statin, no LDL target. No eGFR-slope effect; ΔLDL ~−40% in wks. SHARP (PMID 21663949): major atherosclerotic events RR 0.83 (0.74–0.94), p=0.0021 in CKD

Setting playbook (outpatient) — Slow progression with KDIGO 2024 4-pillar (RAS + SGLT2i + finerenone + statin), prevent CV events, prepare for RRT only when needed
3. lisinopril/losartan Lisinopril 10-40 mg PO daily; losartan 50-100 mg PO daily — UACR ≥30 (KDIGO 2024 foundation; REIN (Ruggenenti Lancet 1998); titrate to max tolerated)
4. dapagliflozin/empagliflozin 10 mg PO daily PO daily — eGFR ≥20 (DAPA-CKD (Heerspink NEJM 2020) / EMPA-KIDNEY (Herrington NEJM 2023))
5. finerenone 10 mg PO daily, up to 20 mg PO daily — DKD + UACR ≥30 + K <5.0 + eGFR ≥25 (FIDELIO-DKD (Bakris NEJM 2020) / FIGARO-DKD (Pitt NEJM 2021))
6. semaglutide 0.25 mg SC weekly, titrate to 1-2 mg SC weekly — DM2 + CKD + not at glycemic target on metformin/SGLT2i (FLOW (Perkovic NEJM 2024); ADA 2026 §11)
7. atorvastatin 20-80 mg PO daily PO daily — Age 50-79 + no dialysis (SHARP (Baigent Lancet 2011); KDIGO 2013 Lipid)
8. sodium bicarbonate 650 mg PO BID-TID PO BID-TID — HCO3 <22 (KDIGO 2024 alkali therapy)
9. erythropoiesis-stimulating agent Epoetin 50-100 U/kg SC 3x/week OR darbepoetin 0.45 mcg/kg q2w SC 1-3x/week — Hb <10 + iron-replete + no contraindication (KDIGO 2012 Anemia; target Hb 10-11.5)

Non-pharmacologic actions:
- Sodium restriction <2 g/day (KDIGO 2024)
- Protein 0.8 g/kg/day in G3b-G5; 0.6-0.8 with low protein supplemented in G4-G5 (KDIGO 2024)
- Smoking cessation (KDIGO 2024)
- Vaccinations — flu, PCV20, HBV, COVID (KDIGO 2024)
- Avoid NSAIDs, IV contrast unless essential (KDIGO 2024)
- Patient education on sick day rules — hold RAS+SGLT2i+diuretic during AKI/dehydration (KDIGO 2024)

AVOID / contraindication checks:
-  RAS block if K >5.0 (KDIGO 2024)
-  RAS pause if AKI (KDIGO 2024)
-  SGLT2i block if eGFR <20 or active DKA (KDIGO 2024)
-  finerenone block if K >5.0 or eGFR <25 (KDIGO 2024)
-  GLP 1 caution if gastroparesis or pancreatitis (ADA 2026)
-  metformin hold if eGFR <30 (KDIGO 2024)
-  NSAID avoid in CKD (KDIGO 2024)

Monitoring

Regimen monitoring:
- BMP 2 weeks after initiation or titration (KDIGO 2024)
- BMP q3m at steady state (KDIGO 2024)
- UACR q3-6m (KDIGO 2024)
- A1c q3m if DM (ADA 2026)
- Phos PTH Ca q6-12m in G3b-G5 (KDIGO 2017)
- Hb iron q3m in G3b-G5 (KDIGO 2012)

Setting (outpatient) monitoring:
- BMP 1-2 weeks after RAS / finerenone / SGLT2i titration (KDIGO 2024)
- BMP, UACR, eGFR q3-6m at steady state (KDIGO 2024)
- BP q visit (KDIGO 2024)
- Hb, iron q3-6m in G3b-G5 (KDIGO 2012 Anemia)
- Phos, PTH, Ca q6-12m in G3b-G5 (KDIGO 2017 CKD-MBD)

Follow-up plan: Cadence by KDIGO 2024 stage; vaccinations (flu/pneumo/HBV/COVID); patient education; CKM review (Ndumele Circulation 2023)
- Close-out criterion: Follow-up scheduled

Monitoring phase: BMP within 1–2 weeks of titration; UACR + eGFR q3–6m; K trend on RAS + finerenone; A1c q3m if DM (KDIGO 2024)

Disposition

Current setting: outpatient — Slow progression with KDIGO 2024 4-pillar (RAS + SGLT2i + finerenone + statin), prevent CV events, prepare for RRT only when needed

Disposition criteria:
- Continue current stage management if stable (KDIGO 2024)
- Advance to vascular access prep when eGFR <30 (KDIGO 2024)
- RRT initiation when eGFR <10 or uremic symptoms (KDIGO 2012)

Escalation triggers (move to higher acuity):
- eGFR decline >3 mL/min/yr → nephrology referral (KDIGO 2024)
- eGFR <30 → vascular access education + nephrology referral (KDIGO 2024)
- eGFR <20 → AV fistula creation; transplant referral (KDIGO 2024)
- K >5.5 on RAS → pause RAS / add patiromer; reassess (KDIGO 2024)
- AKI on CKD → ED / inpatient (KDIGO 2012)

Patient Action Plan

**CKD Sick Day & Self-Monitoring Action Plan (KDIGO 2024)**
Personalised values: baseline_creatinine, baseline_eGFR, current_RAS, current_SGLT2i, current_diuretic, home_BP_target.

**Stable — feeling well** (green):
Triggers:
- Eating and drinking normally (KDIGO 2024)
- No vomiting / diarrhea / fever (KDIGO 2024)
- Home BP at goal SBP <120-130 (KDIGO 2024)
- No new medications (KDIGO 2024)
Actions:
- Continue all CKD medications as prescribed — RAS, SGLT2i, finerenone, statin (KDIGO 2024)
- Stay well hydrated — water; avoid dehydration (KDIGO 2024)
- Avoid NSAIDs — ibuprofen, naproxen, diclofenac (KDIGO 2024)
- Keep all labs and follow-ups (KDIGO 2024)

**Caution — mild illness** (yellow):
Triggers:
- Vomiting or diarrhea more than 1-2 episodes (KDIGO 2024)
- Decreased oral intake or dehydration (KDIGO 2024)
- Fever (KDIGO 2024)
- Unable to keep down medications (KDIGO 2024)
- Home BP much higher or lower than usual (KDIGO 2024)
Actions:
- HOLD: ACEi/ARB, SGLT2i, diuretic, NSAIDs, metformin — sick day rules (KDIGO 2024)
- Drink small frequent sips of water/electrolyte solution (KDIGO 2024)
- Continue blood pressure monitoring (KDIGO 2024)
- Call CKD clinic / primary care within 24 hours for guidance (KDIGO 2024)
- Resume medications when eating/drinking normally — confirm with provider (KDIGO 2024)
Contact provider when:
- Symptoms persist >24 hours (KDIGO 2024)
- Unable to drink fluids (KDIGO 2024)
- Decreased urination (KDIGO 2024)
- New leg swelling or shortness of breath (KDIGO 2024)

**Medical alert — severe illness** (red):
Triggers:
- No urine output for ≥6-8 hours (KDIGO 2012)
- Severe shortness of breath / chest pain (KDIGO 2012)
- Confusion, severe weakness, fainting (KDIGO 2012)
- Severe vomiting/diarrhea unable to keep fluids down (KDIGO 2012)
- Black/tarry stools or vomiting blood (KDIGO 2012)
- Severe leg swelling with shortness of breath — volume overload (KDIGO 2012)
Actions:
- Go to ED immediately (KDIGO 2012)
- Bring complete medication list (KDIGO 2024)
- Tell ED you have CKD and your baseline creatinine (KDIGO 2024)
- Do not take any new NSAIDs or contrast-requiring imaging until stable (KDIGO 2024)
Contact provider when:
- Any red zone symptom — go to ED now (KDIGO 2012)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Uremic pericarditis / encephalopathy / bleeding diathesis (KDIGO 2012)
- [SEVERE] eGFR <15 OR uremic symptoms — encephalopathy, pericarditis, anorexia, pruritus (KDIGO 2012)
- [MODERATE] eGFR decline >3 mL/min/yr OR doubling of UACR (KDIGO 2024)

Citations

- KDIGO 2024 CKD Guideline (Kidney Int Mar 2024) + KDIGO 2024 Diabetes-in-CKD update + 2025 AHA/ACC HTN Guideline + ADA Standards of Care 2026 + 2022 AHA/ACC/HFSA HF Guideline (cardiorenal protective Rx) + 2023 ACC/AHA/HFSA HF Focused Update (finerenone in HFmrEF/HFpEF) + KDIGO 2013 Lipid + KDIGO 2017 CKD-MBD + KDIGO 2012 Anemia [PMID:38490803](https://pubmed.ncbi.nlm.nih.gov/38490803/)
- Cited evidence (PMID 32970396) [PMID:32970396](https://pubmed.ncbi.nlm.nih.gov/32970396/)
- Cited evidence (PMID 33338413) [PMID:33338413](https://pubmed.ncbi.nlm.nih.gov/33338413/)
- Cited evidence (PMID 36331190) [PMID:36331190](https://pubmed.ncbi.nlm.nih.gov/36331190/)
- Cited evidence (PMID 30990260) [PMID:30990260](https://pubmed.ncbi.nlm.nih.gov/30990260/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2024 CKD Guideline (Kidney Int Mar 2024) + KDIGO 2024 Diabetes-in-CKD update + 2025 AHA/ACC HTN Guideline + ADA Standards of Care 2026 + 2022 AHA/ACC/HFSA HF Guideline (cardiorenal protective Rx) + 2023 ACC/AHA/HFSA HF Focused Update (finerenone in HFmrEF/HFpEF) + KDIGO 2013 Lipid + KDIGO 2017 CKD-MBD + KDIGO 2012 Anemia — PMID:38490803
  • Cited evidence (PMID 32970396) — PMID:32970396
  • Cited evidence (PMID 33338413) — PMID:33338413
  • Cited evidence (PMID 36331190) — PMID:36331190
  • Cited evidence (PMID 30990260) — PMID:30990260