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renal.ckd-progression.v1PRODUCTION
renal.ckd-progression.v1

CKD Progression & Management (G1-G5 + ACR stratified)

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

KDIGO heat-map stage (G × A) + etiology + complications (CKD-MBD, anemia, acidosis) (KDIGO 2012 CKD)

Inputs
3
Actions
0
Advance rule
Set
Advance when

KDIGO stage + etiology + complications documented (KDIGO 2012 CKD)

Patient inputs (12)

Age informs eGFR formula + transplant candidacy + treatment intensity (KDIGO 2012 CKD)

Core eGFR input — KDIGO staging G1-G5 (KDIGO 2012 CKD; KDIGO 2024 race-free eGFR)

Albuminuria sub-staging A1/A2/A3 + KDIGO heat-map risk (KDIGO 2012 CKD)

RAS + spironolactone + finerenone tolerability (KDIGO 2024)

BP target <130/80 (or <120/70 SPRINT) (KDIGO 2012 CKD; AHA 2017)

Cause matters — DKD, HTN, GN, PKD, obstructive each have specific Rx (KDIGO 2012 CKD)

Med reconciliation; nephrotoxin avoidance; tier ladder (KDIGO 2012 CKD)

CKD-MBD — phosphate target <5.5 (KDIGO CKD-MBD 2017)

CKD-MBD — sHPT diagnosis + monitoring (KDIGO CKD-MBD 2017)

CKD-MBD — calcium target (KDIGO CKD-MBD 2017)

Anemia of CKD — Hgb <10 + iron-replete → ESA (KDIGO 2012 anemia)

Metabolic acidosis — HCO3 <22 → sodium bicarbonate (KDIGO 2012 CKD)

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

Severity triggers (13)

13 need judgement
  • informationalsevereckd_g4
    CKD G4 (eGFR 15-29) — transplant evaluation + RRT planning + AVF placement 6 mo lead time (KDIGO 2012 CKD; KDOQI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereckd_g5_pre_dialysis_or_dialysis
    CKD G5 (eGFR <15) — RRT decision + initiation per symptoms; conservative-care option per shared decision (KDIGO 2012 CKD; KDIGO 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereckd_g5_vascular_access_failure
    CKD G5 with vascular access planning failure — AVF non-maturation / thrombosis / infection; bridge with CVC + revision (KDOQI 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapid_progressor_ge_5_ml_min_per_y
    Rapid progressor — eGFR decline ≥5 mL/min/y; intensify tier ladder + biopsy if atypical + transplant evaluation early (KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereesrd_palliative_care_no_dialysis_choice
    ESRD palliative-care option — elderly + frail + comorbid; comprehensive conservative care without dialysis; symptom management (KDIGO 2015 conservative care)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereakion_ckd_acute_decompensation
    AKI-on-CKD acute decompensation — sudden Cr rise + volume/acid-base derangement; hold nephrotoxins, treat AKI cause, resume tier ladder (KDIGO 2012 AKI; KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_g3b
    CKD G3b (eGFR 30-44) — twice-yearly labs + mandatory nephrology consult; intensify tier ladder (KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatealbuminuria_a1_a2_a3_sub_staging
    Albuminuria sub-staging — A1 normal (<30), A2 moderate (30-300), A3 severe (>300); A3 drives aggressive renoprotection + finerenone consideration (KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_mbd_mineral_bone_disorder
    CKD-MBD — phosphate >5.5 + iPTH elevated + Ca abnormal; phosphate binder + active vitamin D + calcimimetic per KDIGO CKD-MBD 2017
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanemia_of_ckd
    Anemia of CKD — Hgb <10 + iron-replete (TSAT ≥30%, ferritin ≥500) → ESA + iron; target Hgb 10-11.5 (avoid >13 per CHOIR/CREATE/TREAT) (KDIGO 2012 anemia)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildckd_g1_g2_albuminuria
    CKD G1-G2 (eGFR ≥60) with persistent albuminuria A2/A3 — risk factor modification + RAS + SGLT2i + lifestyle (KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildckd_g3a
    CKD G3a (eGFR 45-59) — annual labs; nephrology consult if A2+ (KDIGO 2012 CKD)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmetabolic_acidosis_of_ckd
    Metabolic acidosis of CKD — HCO3 <22 → sodium bicarbonate supplementation; slows CKD progression + reduces muscle wasting (de Brito-Ashurst JASN 2009)
    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

CKD progression 6-tier ladder — Tier 1 RAS + SGLT2i + statin + BP/A1c foundation → Tier 2 finerenone (DKD-albuminuric) → Tier 3 GLP-1 RA → Tier 4 CKD-MBD (binder + vit D + calcimimetic) → Tier 5 anemia (ESA + iron) + acidosis (bicarb) → Tier 6 transplant/RRT/AVF/conservative (KDIGO 2012 CKD; KDIGO 2022; KDIGO CKD-MBD 2017)
axis: ckd_progression_kdigo_tier_ladderstep tier_1_foundation - Tier 1 — Foundation (RAS + SGLT2i + statin + BP/A1c + lifestyle) for any proteinuric or diabetic CKD
Selected step "Tier 1 — Foundation (RAS + SGLT2i + statin + BP/A1c + lifestyle) for any proteinuric or diabetic CKD" — All CKD with proteinuria ≥0.5 g/d OR DM; any KDIGO stage (KDIGO 2012; KDIGO 2022)
  • lisinopril
    first line
    acei
    10 mg PO daily, titrate to max tolerated (40 mg) • PO • daily
    triggers: proteinuria_or_htn
    KDIGO 2012 CKD — max-tolerated ACEi/ARB; titrate to BP <120/70 (SPRINT) or <130/80
    rxcui 29046
  • losartan
    first line
    arb
    50-100 mg PO daily, titrate to max tolerated • PO • daily
    triggers: acei_intolerant
    KDIGO 2012 CKD — ARB equivalent first-line
    rxcui 52175
  • empagliflozin
    first line
    sglt2i
    10 mg PO daily • PO • daily
    triggers: ckd_egfr_gte_20
    EMPA-KIDNEY 2023 PMID 36331190 — empagliflozin slows CKD progression in broader eGFR + proteinuria spectrum
    rxcui 1545653
  • dapagliflozin
    first line
    sglt2i
    10 mg PO daily • PO • daily
    triggers: ckd_egfr_gte_25
    DAPA-CKD Heerspink NEJM 2020 — slows CKD progression in proteinuric CKD
    rxcui 1488564
  • canagliflozin
    first line
    sglt2i
    100 mg PO daily • PO • daily
    triggers: dkd_t2dm_uacr_gt_300, egfr_gte_30
    CREDENCE Perkovic NEJM 2019 — canagliflozin renal primary endpoint in DKD
    rxcui 1373458
  • atorvastatin
    first line
    statin
    40-80 mg PO daily (high-intensity per ACC/AHA Lipid 2026) • PO • daily
    triggers: ckd_with_ascvd_risk
    ACC/AHA Lipid 2026 — high-intensity statin per ASCVD risk in CKD
    rxcui 83367

outpatient playbook — drug actions (5)

  1. 1. Tier 1 RAS + SGLT2i + statin + BP/A1c titration
    Up-titrate q2-4 wk to target • PO • daily
    trigger: Tier 1 optimization
    KDIGO 2012 CKD
  2. 2. Tier 2 finerenone (if T2DM + albuminuric + eGFR ≥25 + K+ ≤4.8)
    10-20 mg PO daily • PO • daily
    trigger: Tier 2 add-on
    FIDELIO + FIGARO
  3. 3. Tier 3 GLP-1 RA (if T2DM + residual)
    Per agent • SC • weekly or daily
    trigger: Tier 3 add-on
    FLOW + LEADER
  4. 4. Tier 4 CKD-MBD — phosphate binder + active vitamin D ± calcimimetic
    Per labs • PO • TID with meals or daily
    trigger: CKD-MBD signals
    KDIGO CKD-MBD 2017
  5. 5. Tier 5 anemia (ESA + iron) + bicarbonate
    Per labs • SC + PO • per Rx
    trigger: Hgb <10 or HCO3 <22
    KDIGO 2012 anemia + de Brito-Ashurst

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Rising creatinine or declining eGFR on annual screening (KDIGO 2012 CKD); Persistent albuminuria A2/A3 (UACR ≥30 mg/g for ≥3 mo) (KDIGO 2012 CKD); CKD on problem list (continuation visit).

Objective

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

Assessment

**CKD Progression & Management (G1-G5 + ACR stratified)** (renal.ckd-progression.v1).
Phenotype framing: CKD etiology — DKD / hypertensive nephropathy / GN (IgAN, lupus, FSGS, MN) / PKD / obstructive / chronic AIN / atherosclerotic / amyloid (KDIGO 2012 CKD)
Scope: KDIGO heat-map stage (G × A) + etiology + complications (CKD-MBD, anemia, acidosis) (KDIGO 2012 CKD)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CKD progression 6-tier ladder — Tier 1 RAS + SGLT2i + statin + BP/A1c foundation → Tier 2 finerenone (DKD-albuminuric) → Tier 3 GLP-1 RA → Tier 4 CKD-MBD (binder + vit D + calcimimetic) → Tier 5 anemia (ESA + iron) + acidosis (bicarb) → Tier 6 transplant/RRT/AVF/conservative (KDIGO 2012 CKD; KDIGO 2022; KDIGO CKD-MBD 2017)** — step "Tier 1 — Foundation (RAS + SGLT2i + statin + BP/A1c + lifestyle) for any proteinuric or diabetic CKD".
1. lisinopril 10 mg PO daily, titrate to max tolerated (40 mg) PO daily (acei, first line) — KDIGO 2012 CKD — max-tolerated ACEi/ARB; titrate to BP <120/70 (SPRINT) or <130/80
2. losartan 50-100 mg PO daily, titrate to max tolerated PO daily (arb, first line) — KDIGO 2012 CKD — ARB equivalent first-line
3. empagliflozin 10 mg PO daily PO daily (sglt2i, first line) — EMPA-KIDNEY 2023 PMID 36331190 — empagliflozin slows CKD progression in broader eGFR + proteinuria spectrum
4. dapagliflozin 10 mg PO daily PO daily (sglt2i, first line) — DAPA-CKD Heerspink NEJM 2020 — slows CKD progression in proteinuric CKD
5. canagliflozin 100 mg PO daily PO daily (sglt2i, first line) — CREDENCE Perkovic NEJM 2019 — canagliflozin renal primary endpoint in DKD
6. atorvastatin 40-80 mg PO daily (high-intensity per ACC/AHA Lipid 2026) PO daily (statin, first line) — ACC/AHA Lipid 2026 — high-intensity statin per ASCVD risk in CKD

Setting playbook (outpatient) — CKD progression management — tier ladder execution + KDIGO heat-map tracking + transplant + RRT planning + multidisciplinary co-management (KDIGO 2012 CKD)
7. Tier 1 RAS + SGLT2i + statin + BP/A1c titration Up-titrate q2-4 wk to target PO daily — Tier 1 optimization (KDIGO 2012 CKD)
8. Tier 2 finerenone (if T2DM + albuminuric + eGFR ≥25 + K+ ≤4.8) 10-20 mg PO daily PO daily — Tier 2 add-on (FIDELIO + FIGARO)
9. Tier 3 GLP-1 RA (if T2DM + residual) Per agent SC weekly or daily — Tier 3 add-on (FLOW + LEADER)
10. Tier 4 CKD-MBD — phosphate binder + active vitamin D ± calcimimetic Per labs PO TID with meals or daily — CKD-MBD signals (KDIGO CKD-MBD 2017)
11. Tier 5 anemia (ESA + iron) + bicarbonate Per labs SC + PO per Rx — Hgb <10 or HCO3 <22 (KDIGO 2012 anemia + de Brito-Ashurst)

Non-pharmacologic actions:
- Multidisciplinary co-management — nephrology + cardiology + endocrinology + nutrition + social work (KDIGO 2012 CKD)
- Vaccinations per ACIP 2026 (flu, pneumococcal, COVID-19, RSV, shingles, HBV)
- Nutrition + low-Na + protein 0.8 g/kg/d + phosphate restriction (KDIGO 2012 CKD; KDIGO CKD-MBD 2017)
- Transplant referral evaluation at eGFR <30 (G4) (KDIGO 2012 CKD)
- AVF placement 6 months pre-anticipated RRT (KDOQI 2019)
- Pre-RRT shared decision-making — dialysis vs conservative (KDIGO 2015)
- Renal palliative-care consult for symptom management (KDIGO 2015)
- Smoking cessation + cardiac rehab + statin titration (Lipid 2026)

AVOID / contraindication checks:
- K_above_5.5_reduce_ras_mra_finerenone (KDIGO 2024)
- Sglt2i_egfr_lt_20_hold_or_dose adjust (EMPA KIDNEY 2023)
- Sglt2i_sick_day_hold (KDIGO 2022)
- No_nsaids_in_ckd (KDIGO 2012 CKD)
- Contrast_pre_hydration_per_kdigo_2024 (KDIGO 2024)
- Metformin_egfr_lt_30_hold (ADA 2026)
- Pregnancy_discontinue_acei_arb_sglt2i_finerenone (KDIGO 2022)
- Esa_target_hgb_10_to_11.5_avoid_above_13 (CHOIR/CREATE/TREAT)

Monitoring

Regimen monitoring:
- eGFR + UACR + K+ q3-6 mo (varies by stage) (KDIGO 2012 CKD)
- iPTH + Ca + phos q6-12 mo (G3a-G4); q3-6 mo (G5/dialysis) (KDIGO CKD-MBD 2017)
- Hgb + iron studies q3 mo on ESA (KDIGO 2012 anemia)
- Bicarbonate q3-6 mo (KDIGO 2012 CKD)
- BP home log + clinic measurement (KDIGO 2012 CKD)
- K+ q1-2 wk after RAS/finerenone titration (FIDELIO 2020)
- eGFR slope quarterly — flag >5/y as rapid progressor (KDIGO 2012 CKD)
- A1c q3-6 mo if DM (KDIGO 2022 Diabetes-in-CKD)

Setting (outpatient) monitoring:
- BMP + UACR q3-6 mo (KDIGO 2012 CKD)
- iPTH + phos + Ca q6-12 mo G3a-G4; q3-6 mo G5/dialysis (KDIGO CKD-MBD 2017)
- Hgb + iron q3 mo on ESA (KDIGO 2012 anemia)
- Bicarbonate q3-6 mo (KDIGO 2012 CKD)
- eGFR slope quarterly (KDIGO 2012 CKD)
- K+ q1-2 wk after RAS/MRA/finerenone titration; q3-6 mo stable (FIDELIO 2020)

Follow-up plan: q3-6 mo nephrology; transplant + RRT planning at G4 (eGFR <30); AVF placement 6 mo pre-RRT; pre-RRT immunization + nutrition + psychosocial; conservative-care choice (KDIGO 2012 CKD; KDIGO 2015)
- Close-out criterion: Long-term plan documented (KDIGO 2012 CKD)

Monitoring phase: eGFR + UACR + K+ + phos + iPTH + Hgb + bicarb q3-6 mo (varies by stage); eGFR slope quarterly (KDIGO 2012 CKD)

Disposition

Current setting: outpatient — CKD progression management — tier ladder execution + KDIGO heat-map tracking + transplant + RRT planning + multidisciplinary co-management (KDIGO 2012 CKD)

Disposition criteria:
- Continue nephrology q3-6 mo if stable (KDIGO 2012 CKD)
- Admit if AKI-on-CKD / uremic emergency / nephrotic flare / RRT initiation (KDIGO 2012 CKD)

Escalation triggers (move to higher acuity):
- Rising Cr >30% on RAS → reduce dose; rule out volume loss + nephrotoxin (KDIGO 2012 CKD)
- K+ >5.5 → reduce MRA/finerenone/RAS; binder (patiromer/SZC) if persistent (KDIGO 2024)
- Atypical features (rapid Cr rise, hematuria + RBC casts) → biopsy (KDIGO 2012 CKD)
- Rapid eGFR decline >5/y → workup for accelerated CKD or NDD (KDIGO 2012 CKD)
- eGFR <30 → transplant evaluation + AVF planning + pre-RRT education (KDIGO 2012 CKD)
- Symptomatic uremia (anorexia, N/V, pruritus, encephalopathy) → admit for RRT initiation (KDIGO 2012 CKD)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] CKD G4 (eGFR 15-29) — transplant evaluation + RRT planning + AVF placement 6 mo lead time (KDIGO 2012 CKD; KDOQI 2019)
- [SEVERE] CKD G5 (eGFR <15) — RRT decision + initiation per symptoms; conservative-care option per shared decision (KDIGO 2012 CKD; KDIGO 2015)
- [SEVERE] CKD G5 with vascular access planning failure — AVF non-maturation / thrombosis / infection; bridge with CVC + revision (KDOQI 2019)

Citations

- KDIGO 2024 CKD + KDIGO 2021 BP in CKD + SGLT2i (DAPA-CKD 2020, EMPA-KIDNEY 2023) + finerenone (FIDELIO-DKD 2020) + SPRINT intensive BP target [PMID:38490803](https://pubmed.ncbi.nlm.nih.gov/38490803/)
- Cited evidence (PMID 33637192) [PMID:33637192](https://pubmed.ncbi.nlm.nih.gov/33637192/)
- Cited evidence (PMID 32970396) [PMID:32970396](https://pubmed.ncbi.nlm.nih.gov/32970396/)
- Cited evidence (PMID 36331190) [PMID:36331190](https://pubmed.ncbi.nlm.nih.gov/36331190/)
- Cited evidence (PMID 33264825) [PMID:33264825](https://pubmed.ncbi.nlm.nih.gov/33264825/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2024 CKD + KDIGO 2021 BP in CKD + SGLT2i (DAPA-CKD 2020, EMPA-KIDNEY 2023) + finerenone (FIDELIO-DKD 2020) + SPRINT intensive BP target — PMID:38490803
  • Cited evidence (PMID 33637192) — PMID:33637192
  • Cited evidence (PMID 32970396) — PMID:32970396
  • Cited evidence (PMID 36331190) — PMID:36331190
  • Cited evidence (PMID 33264825) — PMID:33264825