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renal.aki.intrinsic.atn.v1

Acute Kidney Injury — Intrinsic ATN Mechanism

nephrologyacuteadult
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm AKI by KDIGO 2012 staging AND mechanism profile supports intrinsic ATN (FeNa >2%, BUN:Cr <15, muddy-brown casts) (KDIGO 2012 AKI; Carvounis 2002)

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Advance rule
Set
Advance when

KDIGO criteria met + ATN profile (KDIGO 2012 AKI)

Patient inputs (18)

Drug-dose adjustment + RRT candidacy + nephrotoxin tolerance (KDIGO 2012 AKI)

KDIGO staging is Cr trajectory; tubular recovery 1-3 weeks (KDIGO 2012 AKI)

Required to compute Cr ratio for KDIGO stage + judge baseline (KDIGO 2012 AKI)

Hemodynamic context for ischemic ATN + sepsis (KDIGO 2012 AKI; SSC 2026)

Oliguria criteria + post-injury trajectory (KDIGO 2012 AKI)

Aminoglycoside, vanco, contrast, cisplatin, methotrexate, NSAID, ACEi review (KDIGO 2012 AKI)

Muddy-brown granular casts + RTEC define ATN sediment (KDIGO 2012 AKI)

TLS hyperK + rhabdo hyperK + AEIOU threshold (KDIGO 2012 AKI; Cairo-Bishop)

CI-AKI (24-72h post-contrast) phenotype (KDIGO 2012 AKI; PRESERVE NEJM 2018)

Cisplatin/methotrexate ATN + TLS post-chemo (Cairo-Bishop)

Rhabdomyolysis trigger (KDIGO 2012 AKI)

TLS predisposing — bulky lymphoma, AML, ALL, high LDH (Cairo-Bishop)

FeNa >2% supports ATN over pre-renal (KDIGO 2012 AKI; Carvounis 2002)

Urine osm <350 (isosthenuria) supports tubular dysfunction (KDIGO 2012 AKI)

TLS hyperuricemia >8 mg/dL or 25% rise (Cairo-Bishop)

Rhabdomyolysis CK >5000 + myoglobinuria (KDIGO 2012 AKI)

Sepsis / shock screening + cisplatin lactic acidosis (SSC 2026)

TLS hyperphos + AKI of any cause; also low phos with refeeding (Cairo-Bishop)

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

Severity triggers (12)

12 need judgement
  • informationallife_threateningtumor_lysis_syndrome
    Tumor lysis syndrome — hyperK + hyperPhos + hyperuricemia + hypoCa post-chemo or hematologic malignancy (Cairo-Bishop)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereischemic_atn_sepsis
    Ischemic ATN — shock with sustained hypoperfusion; sepsis-AKI is most common ICU phenotype (KDIGO 2012 AKI; SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_atn
    Rhabdomyolysis-ATN — CK >5000 U/L + myoglobinuria + hyperK; crush/exertion/seizure/statin/drug (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecisplatin_methotrexate_atn
    Cisplatin or methotrexate ATN — chemo-specific tubular toxicity; cisplatin amifostine + hydration, methotrexate leucovorin rescue + urinary alkalinization (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremyeloma_cast_nephropathy
    Myeloma cast nephropathy — proteinuria + free light chains + AKI in plasma cell dyscrasia (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepigment_nephropathy_hemoglobin
    Pigment nephropathy from hemoglobinuria — intravascular hemolysis (TMA, severe G6PD crisis, transfusion reaction, snake venom) (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecalciphylaxis_renal
    Renal calciphylaxis (calcific uremic arteriolopathy) — rare; CKD/ESRD + calcium-phosphate dysregulation + warfarin association (KDIGO 2024 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverekdigo_stage_3_atn
    KDIGO Stage 3 intrinsic ATN — Cr ≥3× baseline OR Cr ≥4.0 OR UOP <0.3 mL/kg/h × 24h OR anuria ≥12h OR RRT initiated (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenephrotoxic_atn_aminoglycoside
    Aminoglycoside ATN — once-daily dosing + trough monitoring; alternative β-lactam preferred when feasible (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenephrotoxic_atn_vancomycin
    Vancomycin AUC-targeted ATN — AUC 400-600 mg·h/L preferred over trough-only monitoring (Rybak 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprogression_to_ckd_post_atn
    Post-ATN AKD/CKD progression — eGFR <60 sustained at 3 months — transition to CKD trajectory (KDIGO 2024 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildcontrast_induced_aki
    Contrast-induced AKI — 24-72h post-contrast; PRESERVE-negative for prophylactic NaHCO3 + NAC; usually recovers (KDIGO 2012 AKI; PRESERVE Weisbord NEJM 2018)
    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

Intrinsic ATN supportive + sub-phenotype-specific (avoid over-resuscitation; sub-phenotype-targeted antidote/replacement) (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
axis: intrinsic_atn_supportive_and_specificstep discontinue_nephrotoxin - Discontinue / modify nephrotoxin — aminoglycoside extend interval or switch β-lactam; vanco AUC-target; avoid IV contrast; cisplatin amifostine; methotrexate leucovorin rescue (KDIGO 2012 AKI)
Selected step "Discontinue / modify nephrotoxin — aminoglycoside extend interval or switch β-lactam; vanco AUC-target; avoid IV contrast; cisplatin amifostine; methotrexate leucovorin rescue (KDIGO 2012 AKI)" — Active nephrotoxin contributing to ATN (KDIGO 2012 AKI)
  • discontinue_nephrotoxin
    first line
    medication_management
    triggers: active_nephrotoxin, atn_phenotype
    KDIGO 2012 AKI — first-line action; review every drug for renal dosing + alternative selection
  • vancomycin
    contraindication substitute
    glycopeptide
    AUC-targeted 400-600 mg·h/L; load 25 mg/kg; trough goal removed • IV • per AUC
    triggers: vanco_nephrotoxicity
    Rybak ASHP/IDSA/PIDS 2020 PMID 32658968 — AUC-targeted dosing reduces nephrotoxicity vs trough-only (KDIGO 2012 AKI)
    rxcui 11124
  • leucovorin
    rescue
    folinic_acid_rescue
    15 mg/m² q6h until methotrexate <0.1 µmol/L • IV • q6h
    triggers: methotrexate_aki
    Methotrexate ATN rescue + urinary alkalinization to urine pH >7.5; route oncology (KDIGO 2012 AKI)
    rxcui 6313

outpatient playbook — drug actions (3)

  1. 1. restart ACEi/ARB cautiously (if held)
    Half prior dose; recheck Cr+K 1-2 weeks • PO • daily
    trigger: Post-ATN recovery with stable Cr ≥1 week (KDIGO 2024 CKD)
    Renoprotection long-term; avoid permanent discontinuation unless severe AIN
  2. 2. SGLT2 inhibitor
    Empagliflozin 10 mg or dapagliflozin 10 mg PO daily • PO • daily
    trigger: eGFR ≥20 + diabetic or proteinuric CKD post-AKI
    EMPA-KIDNEY/DAPA-CKD slow progression — sick-day hold for AGE (KDIGO 2024 CKD)
  3. 3. statin
    Moderate-intensity per ASCVD risk • PO • daily
    trigger: Post-AKI CV risk modification
    ACC/AHA Lipid 2026; KDIGO 2024 CKD

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Muddy-brown granular casts + renal tubular epithelial cells on urine micro (KDIGO 2012 AKI); FeNa >2% + BUN:Cr <15 + urine osm <350 (KDIGO 2012 AKI; Carvounis 2002); Sepsis / septic shock + sustained hypoperfusion + AKI (SSC 2026; KDIGO 2012 AKI).

Objective

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

Assessment

**Acute Kidney Injury — Intrinsic ATN Mechanism** (renal.aki.intrinsic.atn.v1).
Phenotype framing: ATN sub-phenotypes: ischemic / aminoglycoside / vancomycin AUC / CI-AKI / rhabdomyolysis / TLS / cisplatin-methotrexate / myeloma cast / pigment / calciphylaxis (KDIGO 2012 AKI; PRESERVE NEJM 2018; Cairo-Bishop)
Scope: Confirm AKI by KDIGO 2012 staging AND mechanism profile supports intrinsic ATN (FeNa >2%, BUN:Cr <15, muddy-brown casts) (KDIGO 2012 AKI; Carvounis 2002)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Intrinsic ATN supportive + sub-phenotype-specific (avoid over-resuscitation; sub-phenotype-targeted antidote/replacement) (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)** — step "Discontinue / modify nephrotoxin — aminoglycoside extend interval or switch β-lactam; vanco AUC-target; avoid IV contrast; cisplatin amifostine; methotrexate leucovorin rescue (KDIGO 2012 AKI)".
1. discontinue_nephrotoxin (medication_management, first line) — KDIGO 2012 AKI — first-line action; review every drug for renal dosing + alternative selection
2. vancomycin AUC-targeted 400-600 mg·h/L; load 25 mg/kg; trough goal removed IV per AUC (glycopeptide, contraindication substitute) — Rybak ASHP/IDSA/PIDS 2020 PMID 32658968 — AUC-targeted dosing reduces nephrotoxicity vs trough-only (KDIGO 2012 AKI)
3. leucovorin 15 mg/m² q6h until methotrexate <0.1 µmol/L IV q6h (folinic_acid_rescue, rescue) — Methotrexate ATN rescue + urinary alkalinization to urine pH >7.5; route oncology (KDIGO 2012 AKI)

Setting playbook (outpatient) — Recovery monitoring + permanent nephrotoxin avoidance + CKD progression prevention (KDIGO 2012 AKI; KDIGO 2024 CKD)
4. restart ACEi/ARB cautiously (if held) Half prior dose; recheck Cr+K 1-2 weeks PO daily — Post-ATN recovery with stable Cr ≥1 week (KDIGO 2024 CKD) (Renoprotection long-term; avoid permanent discontinuation unless severe AIN)
5. SGLT2 inhibitor Empagliflozin 10 mg or dapagliflozin 10 mg PO daily PO daily — eGFR ≥20 + diabetic or proteinuric CKD post-AKI (EMPA-KIDNEY/DAPA-CKD slow progression — sick-day hold for AGE (KDIGO 2024 CKD))
6. statin Moderate-intensity per ASCVD risk PO daily — Post-AKI CV risk modification (ACC/AHA Lipid 2026; KDIGO 2024 CKD)

Non-pharmacologic actions:
- Permanent NSAID avoidance counselling (KDIGO 2012 AKI)
- Aminoglycoside / contrast warning card (KDIGO 2012 AKI)
- Sick-day med-rec card (KDIGO 2012 AKI)
- Smoking cessation (KDIGO 2024 CKD)
- Vaccinations per ACIP 2026

AVOID / contraindication checks:
- Aminoglycoside once daily and trough (KDIGO 2012 AKI)
- Vanco auc target 400 600 (Rybak 2020 PMID 32658968)
- Contrast avoid or minimize iso osmolar (KDIGO 2012 AKI; PRESERVE NEJM 2018)
- Rasburicase g6pd screen required (Cairo Bishop)
- Avoid over resuscitation FACTT positive balance harm (Wiedemann NEJM 2006)
- Cisplatin amifostine or hydration required (KDIGO 2012 AKI)
- Methotrexate leucovorin rescue mandatory (KDIGO 2012 AKI)

Monitoring

Regimen monitoring:
- BMP q24h during acute phase (KDIGO 2012 AKI)
- urine output hourly during resuscitation (KDIGO 2012 AKI)
- daily weight (KDIGO 2012 AKI)
- TLS labs q4 6h during chemo (Cairo-Bishop)
- CK q6h during rhabdo phase (KDIGO 2012 AKI)
- vanco AUC during therapy (Rybak 2020)
- glycemic 140 to 180 icu (KDIGO 2012 AKI; NICE-SUGAR)

Setting (outpatient) monitoring:
- eGFR + UACR q3-6 months × 1 year post-AKI (KDIGO 2012 AKI; KDIGO 2024 CKD)
- BP at each visit (KDIGO 2024 CKD)

Follow-up plan: Recheck Cr 1 wk post-discharge; nephrology outpatient; 3-month + 12-month eGFR for CKD progression; permanent NSAID/aminoglycoside avoidance counselling; contrast-avoidance card if CI-AKI history (KDIGO 2012 AKI; KDIGO 2024 CKD)
- Close-out criterion: Follow-up scheduled + patient educated (KDIGO 2012 AKI)

Monitoring phase: Daily Cr until recovery (1-3 wks typical), strict I/O, daily weight, K + acid-base q6-12h during titration, drug-level adjustment (vanco AUC, aminoglycoside trough), CK trajectory rhabdo, TLS labs q4-6h (KDIGO 2012 AKI; Cairo-Bishop)

Disposition

Current setting: outpatient — Recovery monitoring + permanent nephrotoxin avoidance + CKD progression prevention (KDIGO 2012 AKI; KDIGO 2024 CKD)

Disposition criteria:
- Continue outpatient nephrology q3-6 months if eGFR <60 (KDIGO 2024 CKD)
- Transition back to PCP if full Cr recovery + no proteinuria at 12 months (KDIGO 2012 AKI)

Escalation triggers (move to higher acuity):
- Sustained eGFR <60 at 3 months → neph.ckd.core.v1 (KDIGO 2024 CKD)
- Recurrent AKI → nephrology comprehensive evaluation (KDIGO 2012 AKI)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Tumor lysis syndrome — hyperK + hyperPhos + hyperuricemia + hypoCa post-chemo or hematologic malignancy (Cairo-Bishop)
- [SEVERE] Ischemic ATN — shock with sustained hypoperfusion; sepsis-AKI is most common ICU phenotype (KDIGO 2012 AKI; SSC 2026)
- [SEVERE] Rhabdomyolysis-ATN — CK >5000 U/L + myoglobinuria + hyperK; crush/exertion/seizure/statin/drug (KDIGO 2012 AKI)

Citations

- KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + STARRT-AKI NEJM 2020 + AKIKI NEJM 2016 + IDEAL-ICU NEJM 2018 + PRESERVE NEJM 2018 + SMART/SALT-ED NEJM 2018 + Rybak 2020 vanco AUC + Coiffier 2008 TLS/rasburicase + Howard 2011 tumor lysis + Bosch 2009 rhabdomyolysis + SSC 2026 [PMID:22890468](https://pubmed.ncbi.nlm.nih.gov/22890468/)
- Cited evidence (PMID 32668114) [PMID:32668114](https://pubmed.ncbi.nlm.nih.gov/32668114/)
- Cited evidence (PMID 27181456) [PMID:27181456](https://pubmed.ncbi.nlm.nih.gov/27181456/)
- Cited evidence (PMID 30304656) [PMID:30304656](https://pubmed.ncbi.nlm.nih.gov/30304656/)
- Cited evidence (PMID 29130810) [PMID:29130810](https://pubmed.ncbi.nlm.nih.gov/29130810/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + STARRT-AKI NEJM 2020 + AKIKI NEJM 2016 + IDEAL-ICU NEJM 2018 + PRESERVE NEJM 2018 + SMART/SALT-ED NEJM 2018 + Rybak 2020 vanco AUC + Coiffier 2008 TLS/rasburicase + Howard 2011 tumor lysis + Bosch 2009 rhabdomyolysis + SSC 2026 — PMID:22890468
  • Cited evidence (PMID 32668114) — PMID:32668114
  • Cited evidence (PMID 27181456) — PMID:27181456
  • Cited evidence (PMID 30304656) — PMID:30304656
  • Cited evidence (PMID 29130810) — PMID:29130810