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renal.aki.v1PRODUCTION
renal.aki.v1

Acute Kidney Injury

nephrologyacuteadult
Hard-required inputs
0 / 8
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 (Cr +0.3/48h OR 1.5x/7d OR oliguria); rule out pseudo-AKI (KDIGO 2012 AKI)

Inputs
2
Actions
0
Advance rule
Set
Advance when

KDIGO criteria met and not artifactual (KDIGO 2012 AKI)

Patient inputs (14)

Drug dosing + RRT candidacy decisions (KDIGO 2012 AKI)

KDIGO staging is creatinine trajectory (KDIGO 2012 AKI)

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

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

Prerenal hypoperfusion screen + sepsis/cardiogenic shock (KDIGO 2012 AKI)

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

AEIOU dialysis indication; emergent Rx threshold (KDIGO 2012 AKI)

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

Hydronephrosis → postrenal phenotype (KDIGO 2012 AKI)

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

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

Contrast-associated AKI phenotype (KDIGO 2012 AKI; PRESERVE NEJM 2018)

Sediment analysis branches mechanism (RBC casts vs muddy-brown vs eosinophils) (KDIGO 2012 AKI)

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

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

Severity triggers (19)

19 need judgement
  • informationallife_threateningintrinsic_glomerular
    Intrinsic glomerular AKI — nephritic (RPGN) or nephrotic; RBC casts + dysmorphic RBCs + proteinuria → route renal.rpgn.core.v1 (KDIGO 2021 GN)
    Trigger could not be auto-evaluated — needs clinician 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.
  • informationallife_threateningaeiou_acidosis_refractory
    AEIOU Acidosis — pH <7.1 OR HCO3 <10 not responsive to bicarbonate (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningaeiou_hyperkalemia_refractory
    AEIOU Electrolytes — K >6.5 OR ECG changes despite shift therapy + binder (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverekdigo_stage_3
    KDIGO Stage 3 AKI — Cr ≥3× baseline OR Cr ≥4.0 mg/dL OR UOP <0.3 mL/kg/h × ≥24h OR anuria ≥12h OR RRT initiated (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereintrinsic_atn
    Intrinsic AKI — Acute Tubular Necrosis; ischemic or nephrotoxic; FENa >2%, BUN:Cr <15, muddy-brown granular casts (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereintrinsic_vascular
    Intrinsic vascular AKI — renal vein thrombosis / atheroembolic / TTP-HUS / scleroderma renal crisis (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostrenal_obstruction
    Post-renal AKI — obstruction (BPH/pelvic mass/bilateral stones/single-kidney obstruction); hydronephrosis on imaging (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehrs_aki
    Hepatorenal syndrome per ICA 2019 — cirrhosis + AKI not responsive to 48h albumin challenge + no shock + no nephrotoxin (AASLD 2023; ICA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresepsis_aki
    Sepsis-associated AKI — most common ICU AKI; multifactorial (hypoperfusion + cytokine + drugs) (SSC 2026; KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_aki
    Rhabdomyolysis-AKI — CK >5000 U/L + myoglobinuria + hyperK; crush/exertion/seizure/statin/drug (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecardiorenal_syndrome
    Cardiorenal syndrome Types 1-5 (Ronco) — AKI from acute/chronic cardiac dysfunction or vice versa (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaeiou_overload
    AEIOU Overload — pulmonary edema refractory to high-dose IV loop diuretic (KDIGO 2012 AKI; DOSE NEJM 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaeiou_uremia
    AEIOU Uremia — encephalopathy / pericarditis / bleeding diathesis with BUN >100 (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatekdigo_stage_2
    KDIGO Stage 2 AKI — Cr 2.0-2.9× baseline OR UOP <0.5 mL/kg/h × ≥12h (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateprerenal_aki
    Prerenal AKI — volume depletion / cardiorenal / HRS; FENa <1%, BUN:Cr >20, urine osm >500, hyaline casts (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateintrinsic_ain
    Acute Interstitial Nephritis — drug (PPI/NSAID/FQ/β-lactam/ICI)/infection/autoimmune; sterile pyuria + eosinophils + drug exposure (KDIGO 2012 AKI; Gonzalez Kidney Int 2008)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildkdigo_stage_1
    KDIGO Stage 1 AKI — Cr 1.5-1.9× baseline OR ≥0.3 mg/dL increase OR UOP <0.5 mL/kg/h × 6-12h (KDIGO 2012 AKI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildci_aki_contrast_associated
    Contrast-induced/contrast-associated AKI — within 48-72h of contrast; 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

KDIGO 2012 AKI bundle — phenotype-driven volume / nephrotoxin / RRT (KDIGO 2012 AKI; STARRT-AKI NEJM 2020; SMART NEJM 2018)
axis: kdigo_aki_bundlestep volume_resuscitation - Volume resuscitation — balanced crystalloid preferred (SMART/SALT-ED; PLUS/BaSICS mixed)
Selected step "Volume resuscitation — balanced crystalloid preferred (SMART/SALT-ED; PLUS/BaSICS mixed)" — Prerenal pattern (FENa <1%, BUN:Cr >20, urine osm >500) OR sepsis-AKI with hypoperfusion (KDIGO 2012 AKI)
  • lactated_ringers
    first line
    balanced_crystalloid
    10-20 mL/kg bolus • IV • titrate to MAP >65 + UOP >0.5 mL/kg/h
    triggers: prerenal, sepsis_aki, true_volume_depletion
    SMART Semler NEJM 2018 + SALT-ED — balanced crystalloid superior to saline for MAKE30; prevents hyperchloremic acidosis (KDIGO 2012 AKI)
    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 unavailable; avoid large-volume to prevent hyperchloremic acidosis (KDIGO 2012 AKI)
    rxcui 9863

outpatient playbook — drug actions (3)

  1. 1. restart ACEi/ARB cautiously
    Half prior dose, recheck Cr+K in 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 AIN/ATN
  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 (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: Creatinine rise ≥0.3 mg/dL in 48h OR ≥1.5x baseline in 7d (KDIGO 2012 AKI); Urine output <0.5 mL/kg/h × ≥6h (KDIGO 2012 AKI); New anuria or decreased urine output (KDIGO 2012 AKI).

Objective

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

Assessment

**Acute Kidney Injury** (renal.aki.v1).
Phenotype framing: Phenotype: prerenal / ATN / AIN / glomerular (→ renal.rpgn) / vascular / postrenal / CI-AKI / HRS-AKI / sepsis-AKI / rhabdo-AKI / TLS / cardiorenal (KDIGO 2012 AKI)
Scope: Confirm AKI by KDIGO 2012 staging (Cr +0.3/48h OR 1.5x/7d OR oliguria); rule out pseudo-AKI (KDIGO 2012 AKI)

No severity triggers fired against current inputs.

Plan

Regimen axis: **KDIGO 2012 AKI bundle — phenotype-driven volume / nephrotoxin / RRT (KDIGO 2012 AKI; STARRT-AKI NEJM 2020; SMART NEJM 2018)** — step "Volume resuscitation — balanced crystalloid preferred (SMART/SALT-ED; PLUS/BaSICS mixed)".
1. lactated_ringers 10-20 mL/kg bolus IV titrate to MAP >65 + UOP >0.5 mL/kg/h (balanced_crystalloid, first line) — SMART Semler NEJM 2018 + SALT-ED — balanced crystalloid superior to saline for MAKE30; prevents hyperchloremic acidosis (KDIGO 2012 AKI)
2. sodium_chloride_0.9% 10-20 mL/kg bolus IV titrate (crystalloid, second line) — Acceptable when balanced unavailable; avoid large-volume to prevent hyperchloremic acidosis (KDIGO 2012 AKI)

Setting playbook (outpatient) — Post-AKI recovery monitoring; CKD progression prevention; recurrent AKI risk modification (KDIGO 2012 AKI; KDIGO 2024 CKD)
3. restart ACEi/ARB cautiously Half prior dose, recheck Cr+K in 1-2 weeks PO daily — Post-AKI recovery with stable Cr ≥1 week (KDIGO 2024 CKD) (Renoprotection long-term; avoid permanent discontinuation unless severe AIN/ATN)
4. 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 (KDIGO 2024 CKD))
5. 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)
- Sick-day med-rec card (KDIGO 2012 AKI)
- Smoking cessation (KDIGO 2024 CKD)
- BP home monitoring + 24h ABPM if uncontrolled (KDIGO 2024 CKD)
- Vaccination — annual flu, COVID, pneumococcal per ACIP 2026

AVOID / contraindication checks:
- Nsaid acei arb hold in AKI (KDIGO 2012 AKI)
- Contrast avoid or minimize dose (KDIGO 2012 AKI; PRESERVE NEJM 2018)
- Aminoglycoside once daily and trough (KDIGO 2012 AKI)
- Loop diuretic monitor K and Mg (KDIGO 2012 AKI; DOSE NEJM 2011)
- Balanced crystalloid preferred over saline (SMART NEJM 2018)
- Avoid prophylactic nac nahco3 (PRESERVE NEJM 2018)

Monitoring

Regimen monitoring:
- BMP q24h during acute phase (KDIGO 2012 AKI)
- urine output hourly (KDIGO 2012 AKI)
- daily weight (KDIGO 2012 AKI)
- MAP hourly if pressors (KDIGO 2012 AKI)
- glycemic 140 to 180 icu (KDIGO 2012 AKI; NICE-SUGAR)

Setting (outpatient) monitoring:
- eGFR + UACR every 3-6 months × 1 year post-AKI (KDIGO 2012 AKI; KDIGO 2024 CKD)
- BP at each visit (KDIGO 2024 CKD)
- Recurrent AKI risk score documentation (KDIGO 2012 AKI)

Follow-up plan: Recheck Cr 1 week post-discharge; nephrology outpatient; 3-month reassessment for CKD progression; med-rec post-AKI; recurrent AKI risk modification (KDIGO 2012 AKI; KDIGO 2024 CKD)
- Close-out criterion: Follow-up scheduled and patient educated (KDIGO 2012 AKI)

Monitoring phase: Daily Cr until stable, strict I/O, daily weight, K + acid-base q6-12h while titrating, drug-level adjustment, glycemic 140-180 mg/dL ICU (KDIGO 2012 AKI)

Disposition

Current setting: outpatient — Post-AKI recovery monitoring; CKD progression prevention; recurrent AKI risk modification (KDIGO 2012 AKI; KDIGO 2024 CKD)

Disposition criteria:
- Continue outpatient nephrology q3-6 months if eGFR <60 or proteinuria (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 → transition to neph.ckd.core.v1 (KDIGO 2024 CKD)
- Recurrent AKI → nephrology + comprehensive evaluation (KDIGO 2012 AKI)
- Worsening proteinuria → consider GN workup → route renal.rpgn.core.v1 if active sediment (KDIGO 2021 GN)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Intrinsic glomerular AKI — nephritic (RPGN) or nephrotic; RBC casts + dysmorphic RBCs + proteinuria → route renal.rpgn.core.v1 (KDIGO 2021 GN)
- [LIFE_THREATENING] Tumor lysis syndrome — hyperK + hyperPhos + hyperuricemia + hypoCa post-chemo or hematologic malignancy (Cairo-Bishop)
- [LIFE_THREATENING] AEIOU Acidosis — pH <7.1 OR HCO3 <10 not responsive to bicarbonate (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)

Citations

- KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + STARRT-AKI NEJM 2020 + AKIKI NEJM 2016 + IDEAL-ICU NEJM 2018 + SMART/SALT-ED NEJM 2018 + DOSE NEJM 2011 + PRESERVE NEJM 2018 + CONFIRM NEJM 2021 (HRS) + AASLD 2023 ACLF + SSC 2026 sepsis + KDIGO 2024 CKD progression [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 29485925) [PMID:29485925](https://pubmed.ncbi.nlm.nih.gov/29485925/)

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 + SMART/SALT-ED NEJM 2018 + DOSE NEJM 2011 + PRESERVE NEJM 2018 + CONFIRM NEJM 2021 (HRS) + AASLD 2023 ACLF + SSC 2026 sepsis + KDIGO 2024 CKD progression — PMID:22890468
  • Cited evidence (PMID 32668114) — PMID:32668114
  • Cited evidence (PMID 27181456) — PMID:27181456
  • Cited evidence (PMID 30304656) — PMID:30304656
  • Cited evidence (PMID 29485925) — PMID:29485925