Clinical Commander

Back to dossier
renal.aki.prerenal.v1PRODUCTION
renal.aki.prerenal.v1

Acute Kidney Injury — Pre-renal Mechanism

nephrologyacuteadult
Hard-required inputs
0 / 9
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 suggests pre-renal (FeNa <1%, BUN:Cr >20, urine osm >500, hyaline casts) (KDIGO 2012 AKI; Carvounis 2002)

Inputs
2
Actions
0
Advance rule
Set
Advance when

KDIGO criteria met + pre-renal profile (KDIGO 2012 AKI)

Patient inputs (15)

Volume resuscitation tolerance + drug dosing (KDIGO 2012 AKI)

KDIGO staging + Cr response to volume challenge (KDIGO 2012 AKI)

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

Hypoperfusion screen — distributive vs hypovolemic vs cardiogenic shock (KDIGO 2012 AKI; SSC 2026)

Tachycardia supports hypovolemia (KDIGO 2012 AKI)

Oliguria criteria + monitoring response (KDIGO 2012 AKI)

NSAID / ACEi / ARB / diuretic / SGLT2i review (KDIGO 2012 AKI)

BUN:Cr ratio >20:1 supports pre-renal mechanism (KDIGO 2012 AKI; Carvounis 2002)

Hyaline casts (pre-renal); rule out muddy-brown ATN, RBC casts GN (KDIGO 2012 AKI)

HRS-AKI per ICA 2019 — albumin challenge + terlipressin (AASLD 2023)

Cardiorenal type 1 — diuretic + vasodilator strategy (DOSE NEJM 2011)

Vomiting / diarrhea / hemorrhage / burns / NG suction (KDIGO 2012 AKI)

FeNa <1% supports pre-renal (KDIGO 2012 AKI; Carvounis 2002)

Urine osm >500 supports concentrating ability + pre-renal (KDIGO 2012 AKI)

Hypoalbuminemia supports third-spacing; HRS workup (AASLD 2023)

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

Severity triggers (11)

11 need judgement
  • informationallife_threateninghrs_aki_per_ica_2019
    HRS-AKI per ICA 2019 — cirrhosis + AKI + failure to respond to 48h albumin 1 g/kg + no shock + no nephrotoxin + no parenchymal disease on UA/US (AASLD 2023; ICA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningabdominal_compartment_syndrome
    Abdominal compartment syndrome — IAP >20 mmHg + new organ dysfunction; pre-renal AKI from reduced renal perfusion pressure (KDIGO 2012 AKI; WSACS 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverethird_spacing_prerenal
    Pre-renal AKI from third-spacing — pancreatitis, liver failure, sepsis, burns, post-operative; reduced effective circulating volume despite total-body fluid overload (KDIGO 2012 AKI; AASLD 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiorenal_type_1
    Cardiorenal type 1 — acute HF → AKI; volume overload (NOT depletion) + WRF + elevated JVP + edema + pulmonary congestion (DOSE NEJM 2011; AHA/ACC HF 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_renal_artery_stenosis_on_acei
    Bilateral renal artery stenosis unmasked by ACEi/ARB — abrupt Cr rise upon initiation; asymmetric kidneys on US + audible renal bruit (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereprogression_to_atn
    Sustained hypoperfusion → ischemic ATN — FeNa rises >2%, BUN:Cr falls <15, muddy-brown casts replace hyaline; recovery 1-3 weeks (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverekdigo_stage_3_prerenal
    KDIGO Stage 3 pre-renal AKI — 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.
  • informationalmoderatevolume_depletion_prerenal
    Pre-renal AKI from volume depletion — vomiting/diarrhea/diuretic overdose/hemorrhage/burns/NG suction; tachycardia + orthostasis + dry mucous membranes (KDIGO 2012 AKI; Carvounis 2002)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecardiorenal_type_2
    Cardiorenal type 2 — chronic HF + chronic kidney disease baseline; gradual decompensation requires balancing GDMT + diuretic + volume status (AHA/ACC HF 2022; KDIGO 2024 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatensaid_induced_afferent_constriction
    NSAID-induced pre-renal AKI — afferent arteriolar vasoconstriction from prostaglandin inhibition; reversible with NSAID withdrawal (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateacei_arb_induced_efferent_dilation
    ACEi/ARB-induced pre-renal AKI — efferent arteriolar dilation; worsens in volume depletion or bilateral RAS (KDIGO 2012 AKI; KDIGO 2024 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
Loading…

Recommended regimen

Pre-renal AKI — volume + perfusion + cause-specific (balanced crystalloid preferred per SMART/SALT-ED; albumin + terlipressin for HRS) (KDIGO 2012 AKI; SMART NEJM 2018; CONFIRM NEJM 2021)
axis: prerenal_volume_perfusionstep volume_challenge_balanced - Balanced crystalloid volume challenge — first-line for volume-depleted pre-renal AKI (SMART/SALT-ED)
Selected step "Balanced crystalloid volume challenge — first-line for volume-depleted pre-renal AKI (SMART/SALT-ED)" — Volume depletion (GI losses, hemorrhage, diuretic overshoot, third-spacing) + adequate cardiac function (KDIGO 2012 AKI; SMART NEJM 2018)
  • lactated_ringers
    first line
    balanced_crystalloid
    500-1000 mL bolus over 30 min, repeat to UOP >0.5 mL/kg/h + MAP >65 (max 2-3 L without reassessment) • IV • titrate to MAP/UOP
    triggers: volume_depletion, gi_losses, true_prerenal
    SMART Semler NEJM 2018 PMID 29485925 + SALT-ED Self NEJM 2018 PMID 29485926 — balanced crystalloid lowers MAKE30 vs saline; avoids hyperchloremic acidosis (KDIGO 2012 AKI)
    rxcui 847630
  • plasmalyte
    first line
    balanced_crystalloid
    500-1000 mL bolus over 30 min • IV • titrate to MAP/UOP
    triggers: lr_unavailable, lactated_ringers_alternative
    Equivalent balanced crystalloid alternative to LR — BaSICS PMID 34375394 + PLUS PMID 35041780 no harm signal (KDIGO 2012 AKI)
    rxcui 33829
  • sodium_chloride_0.9%
    second line
    crystalloid
    500-1000 mL bolus over 30 min • IV • titrate
    triggers: no_balanced_crystalloid, hypochloremic_alkalosis_present
    Acceptable when balanced unavailable; avoid large-volume to prevent hyperchloremic acidosis (KDIGO 2012 AKI; SMART NEJM 2018)
    rxcui 9863

outpatient playbook — drug actions (3)

  1. 1. restart ACEi/ARB cautiously
    Half prior dose; recheck Cr+K at 1-2 weeks • PO • daily
    trigger: Post-AKI recovery with stable Cr ≥1 week (KDIGO 2024 CKD)
    Renoprotection long-term; avoid permanent discontinuation unless severe ATN/AIN (KDIGO 2024 CKD)
  2. 2. reduce diuretic if over-diuresed
    Lower dose or hold; reassess weight + BNP • PO • daily
    trigger: Iatrogenic diuretic-induced pre-renal AKI
    Match diuresis to volume status (KDIGO 2012 AKI; DOSE NEJM 2011)
  3. 3. 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)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Creatinine rise with FeNa <1% + BUN:Cr >20 (KDIGO 2012 AKI; Carvounis Kidney Int 2002); Oliguria + dehydration / volume loss / GI losses (KDIGO 2012 AKI); Vomiting / diarrhea / hemorrhage / diuretic overuse (KDIGO 2012 AKI).

Objective

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

Assessment

**Acute Kidney Injury — Pre-renal Mechanism** (renal.aki.prerenal.v1).
Phenotype framing: Pre-renal sub-phenotypes: volume-depletion / third-spacing / cardiorenal type 1 / cardiorenal type 2 / HRS-AKI / NSAID-induced / ACEi-ARB-induced / RAS-on-ACEi / abdominal compartment syndrome (KDIGO 2012 AKI; AASLD 2023; ICA 2019)
Scope: Confirm AKI by KDIGO 2012 staging AND mechanism profile suggests pre-renal (FeNa <1%, BUN:Cr >20, urine osm >500, hyaline casts) (KDIGO 2012 AKI; Carvounis 2002)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pre-renal AKI — volume + perfusion + cause-specific (balanced crystalloid preferred per SMART/SALT-ED; albumin + terlipressin for HRS) (KDIGO 2012 AKI; SMART NEJM 2018; CONFIRM NEJM 2021)** — step "Balanced crystalloid volume challenge — first-line for volume-depleted pre-renal AKI (SMART/SALT-ED)".
1. lactated_ringers 500-1000 mL bolus over 30 min, repeat to UOP >0.5 mL/kg/h + MAP >65 (max 2-3 L without reassessment) IV titrate to MAP/UOP (balanced_crystalloid, first line) — SMART Semler NEJM 2018 PMID 29485925 + SALT-ED Self NEJM 2018 PMID 29485926 — balanced crystalloid lowers MAKE30 vs saline; avoids hyperchloremic acidosis (KDIGO 2012 AKI)
2. plasmalyte 500-1000 mL bolus over 30 min IV titrate to MAP/UOP (balanced_crystalloid, first line) — Equivalent balanced crystalloid alternative to LR — BaSICS PMID 34375394 + PLUS PMID 35041780 no harm signal (KDIGO 2012 AKI)
3. sodium_chloride_0.9% 500-1000 mL bolus over 30 min IV titrate (crystalloid, second line) — Acceptable when balanced unavailable; avoid large-volume to prevent hyperchloremic acidosis (KDIGO 2012 AKI; SMART NEJM 2018)

Setting playbook (outpatient) — Recovery monitoring + cautious re-introduction of RAS blockade; deprescribe sustainably; HF/cirrhosis specialty referral (KDIGO 2012 AKI; KDIGO 2024 CKD)
4. restart ACEi/ARB cautiously Half prior dose; recheck Cr+K at 1-2 weeks PO daily — Post-AKI recovery with stable Cr ≥1 week (KDIGO 2024 CKD) (Renoprotection long-term; avoid permanent discontinuation unless severe ATN/AIN (KDIGO 2024 CKD))
5. reduce diuretic if over-diuresed Lower dose or hold; reassess weight + BNP PO daily — Iatrogenic diuretic-induced pre-renal AKI (Match diuresis to volume status (KDIGO 2012 AKI; DOSE NEJM 2011))
6. 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))

Non-pharmacologic actions:
- Permanent NSAID avoidance counselling (KDIGO 2012 AKI)
- Sick-day med-rec card (KDIGO 2012 AKI)
- BP home monitoring (KDIGO 2024 CKD)
- Vaccinations per ACIP 2026
- Hepatology referral if cirrhosis-related pre-renal AKI (AASLD 2023)
- Cardiology if cardiorenal HF baseline (AHA/ACC HF 2022)

AVOID / contraindication checks:
- Nsaid hold permanent after prerenal aki (KDIGO 2012 AKI)
- Acei arb hold during volume depletion (KDIGO 2012 AKI)
- Balanced crystalloid preferred over saline (SMART NEJM 2018; SALT ED NEJM 2018)
- Terlipressin icu monitoring for ischemia respiratory failure (CONFIRM NEJM 2021)
- Albumin 1g per kg cirrhosis challenge (ICA 2019; AASLD 2023)
- Loop diuretic only if volume overloaded not prerenal (KDIGO 2012 AKI; DOSE NEJM 2011)

Monitoring

Regimen monitoring:
- BMP q12 24h during resuscitation (KDIGO 2012 AKI)
- urine output hourly during resuscitation (KDIGO 2012 AKI)
- MAP q15 min during resuscitation (KDIGO 2012 AKI; SSC 2026)
- daily weight (KDIGO 2012 AKI)
- serum albumin during HRS protocol (AASLD 2023)
- chloride acid base if large volume NS (SMART NEJM 2018)

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)
- K + Cr 1-2 weeks after RAS resumption (KDIGO 2024 CKD)

Follow-up plan: Re-introduce ACEi/ARB cautiously post-recovery (KDIGO 2024 CKD); permanent NSAID avoidance; sick-day med-rec for diuretic/SGLT2i/ACEi during AGE; hepatology follow-up for cirrhosis; cardiology for HF (KDIGO 2012 AKI; KDIGO 2024 CKD; AASLD 2023)
- Close-out criterion: Follow-up scheduled + patient educated (KDIGO 2012 AKI)

Monitoring phase: Cr q12-24h until improvement, strict I/O, daily weight, MAP target, electrolytes (post-resuscitation hyperchloremic acidosis with NS), albumin level if HRS protocol (KDIGO 2012 AKI; SMART NEJM 2018; AASLD 2023)

Disposition

Current setting: outpatient — Recovery monitoring + cautious re-introduction of RAS blockade; deprescribe sustainably; HF/cirrhosis specialty referral (KDIGO 2012 AKI; KDIGO 2024 CKD)

Disposition criteria:
- Continue 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)
- Cirrhosis decompensation → hepatology + reassess HRS risk (AASLD 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] HRS-AKI per ICA 2019 — cirrhosis + AKI + failure to respond to 48h albumin 1 g/kg + no shock + no nephrotoxin + no parenchymal disease on UA/US (AASLD 2023; ICA 2019)
- [LIFE_THREATENING] Abdominal compartment syndrome — IAP >20 mmHg + new organ dysfunction; pre-renal AKI from reduced renal perfusion pressure (KDIGO 2012 AKI; WSACS 2013)
- [SEVERE] Pre-renal AKI from third-spacing — pancreatitis, liver failure, sepsis, burns, post-operative; reduced effective circulating volume despite total-body fluid overload (KDIGO 2012 AKI; AASLD 2023)

Citations

- KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + ICA 2015 HRS-AKI consensus + AASLD 2023 ACLF/HRS guidance + AHA/ACC HF 2022 + SMART/SALT-ED NEJM 2018 + CONFIRM NEJM 2021 (terlipressin HRS-AKI) + DOSE NEJM 2011 + KDIGO 2024 CKD progression + WSACS 2013 (abdominal compartment syndrome) [PMID:22890468](https://pubmed.ncbi.nlm.nih.gov/22890468/)
- Cited evidence (PMID 25638527) [PMID:25638527](https://pubmed.ncbi.nlm.nih.gov/25638527/)
- Cited evidence (PMID 33657294) [PMID:33657294](https://pubmed.ncbi.nlm.nih.gov/33657294/)
- Cited evidence (PMID 32668114) [PMID:32668114](https://pubmed.ncbi.nlm.nih.gov/32668114/)
- Cited evidence (PMID 12427149) [PMID:12427149](https://pubmed.ncbi.nlm.nih.gov/12427149/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + ICA 2015 HRS-AKI consensus + AASLD 2023 ACLF/HRS guidance + AHA/ACC HF 2022 + SMART/SALT-ED NEJM 2018 + CONFIRM NEJM 2021 (terlipressin HRS-AKI) + DOSE NEJM 2011 + KDIGO 2024 CKD progression + WSACS 2013 (abdominal compartment syndrome) — PMID:22890468
  • Cited evidence (PMID 25638527) — PMID:25638527
  • Cited evidence (PMID 33657294) — PMID:33657294
  • Cited evidence (PMID 32668114) — PMID:32668114
  • Cited evidence (PMID 12427149) — PMID:12427149