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renal.diabetic-nephropathy.v1PRODUCTION
renal.diabetic-nephropathy.v1

Diabetic Kidney Disease (DKD)

nephrologychronicadult
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 DKD via DM + albuminuria/eGFR-decline + retinopathy support; classify KDIGO heat-map stage (KDIGO 2022 Diabetes-in-CKD)

Inputs
3
Actions
0
Advance rule
Set
Advance when

DKD framework established (KDIGO 2022)

Patient inputs (12)

A1c target individualization + transplant candidacy + treatment intensity (KDIGO 2022 Diabetes-in-CKD)

T1DM vs T2DM drives drug class eligibility (e.g., GLP-1 RA primarily T2DM) (KDIGO 2022)

Long duration + classic albuminuria pattern supports DKD; short duration + atypical → biopsy NDD (KDIGO 2022)

eGFR + CKD staging core to KDIGO heat-map (KDIGO 2022)

Albuminuria stage A1/A2/A3 drives therapy escalation (KDIGO 2022)

Glycemic control target individualized (<7% young, <8% elderly/frail) (KDIGO 2022)

RAS + finerenone tolerability + spironolactone safety (FIDELIO 2020)

BP target <130/80 (consider <120/70 SPRINT-extension) (KDIGO 2022)

Med reconciliation for tier ladder; finerenone + spironolactone K+ stacking (FIDELIO 2020)

Routes cardio.ascvd.chronic.v1 for primary/secondary prevention overlay (ACC/AHA Lipid 2026)

Pregnancy → discontinue ACEi/ARB/SGLT2i/finerenone; switch to nifedipine + labetalol + insulin (KDIGO 2022)

Retinopathy correlates with classic DKD; absence with long DM duration → atypical → biopsy NDD (KDIGO 2022)

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

Severity triggers (9)

9 need judgement
  • informationalsevererapid_progressor_phenotype
    Rapid progressor — eGFR decline >5 mL/min/y; consider biopsy for accelerated DKD or NDD; intensify tier ladder + transplant evaluation early (KDIGO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebiopsy_discordant_ndd
    Biopsy-discordant non-diabetic kidney disease — atypical features (rapid Cr rise, hematuria + RBC casts, low C3/C4, no retinopathy with long DM, nephrotic-range new onset) → biopsy (KDIGO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredkd_with_ascvd
    DKD with concurrent ASCVD — secondary prevention; high-intensity statin + ezetimibe + PCSK9i if needed; SGLT2i + GLP-1 RA add-on (ACC/AHA Lipid 2026; KDIGO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_dkd
    Pregnancy with DKD — discontinue ACEi/ARB/SGLT2i/finerenone (teratogenic); switch to nifedipine + labetalol; insulin for glycemic control; refer high-risk OB + nephrology (KDIGO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereesrd_dkd_transplant_prep
    ESRD DKD — eGFR <15 (G5); transplant evaluation + AVF placement + pre-RRT planning + shared decision-making conservative vs dialysis (KDIGO 2022; KDIGO 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateovert_macroalbuminuria
    Overt DKD — macroalbuminuria >300 mg/g (UACR A3); add finerenone if eGFR ≥25 + K+ ≤4.8 (FIDELIO + FIGARO 2020/2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenon_albuminuric_dkd
    Non-albuminuric DKD — eGFR decline without significant albuminuria; ~20-40% of modern DKD; SGLT2i + RAS still indicated but finerenone benefit less clear (KDIGO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedkd_with_htn_dominant
    DKD with HTN-dominant — uncontrolled HTN >140/90 + DKD; add diuretic + CCB; target <120/70 (SPRINT) or <130/80 (KDIGO 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildincipient_microalbuminuria
    Incipient DKD — microalbuminuria 30-300 mg/g (UACR A2) + eGFR preserved (G1-G2); first-line ACEi/ARB + SGLT2i + glycemic + BP control (KDIGO 2022 Diabetes-in-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
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Recommended regimen

DKD tier ladder — Tier 1 RAS + SGLT2i + statin + BP/A1c (foundational) → Tier 2 finerenone (FIDELIO + FIGARO) → Tier 3 GLP-1 RA (LEADER + FLOW) → Tier 4 transplant/RRT planning (KDIGO 2022 Diabetes-in-CKD)
axis: dkd_tiered_ladder_ras_sglt2i_finerenone_glp1step tier_1_foundation - Tier 1 — Foundational therapy (always — RAS + SGLT2i + statin + BP/A1c + lifestyle)
Selected step "Tier 1 — Foundational therapy (always — RAS + SGLT2i + statin + BP/A1c + lifestyle)" — All DKD patients (any KDIGO stage); albuminuria + diabetes (KDIGO 2022 Diabetes-in-CKD)
  • lisinopril
    first line
    acei
    10 mg PO daily, titrate to max tolerated (40 mg) • PO • daily
    triggers: hypertension_or_albuminuria
    KDIGO 2022 — max-tolerated ACEi/ARB; titrate to BP <130/80 + minimize albuminuria
    rxcui 29046
  • losartan
    first line
    arb
    50-100 mg PO daily, titrate to max tolerated • PO • daily
    triggers: acei_intolerant
    KDIGO 2022 — ARB equivalent first-line if ACEi cough/angioedema
    rxcui 52175
  • empagliflozin
    first line
    sglt2i
    10 mg PO daily • PO • daily
    triggers: dkd, egfr_gte_20
    EMPA-KIDNEY 2023 PMID 36331190 — empagliflozin reduces CKD progression + CV death; KDIGO 2022 Diabetes-in-CKD foundational
    rxcui 1545653
  • dapagliflozin
    first line
    sglt2i
    10 mg PO daily • PO • daily
    triggers: dkd, egfr_gte_25
    DAPA-CKD Heerspink NEJM 2020 — alternative SGLT2i; KDIGO 2022
    rxcui 1488564
  • canagliflozin
    first line
    sglt2i
    100 mg PO daily, titrate to 300 mg if eGFR ≥60 • PO • daily
    triggers: dkd_t2dm_uacr_gt_300, egfr_gte_30
    CREDENCE Perkovic NEJM 2019 — canagliflozin in DKD with renal primary endpoint
    rxcui 1373458
  • atorvastatin
    first line
    statin
    40 mg PO daily (high-intensity if ASCVD or risk) • PO • daily
    triggers: ascvd_or_dkd_with_high_risk
    ACC/AHA Lipid 2026 — high-intensity statin for DKD + ASCVD risk reduction
    rxcui 83367

outpatient playbook — drug actions (4)

  1. 1. Tier 1 RAS + SGLT2i + statin + BP + A1c titration
    Up-titrate q2-4 wk to target • PO • daily
    trigger: Tier 1 optimization
    KDIGO 2022
  2. 2. Finerenone if albuminuric + eGFR ≥25 + K+ ≤4.8
    10-20 mg PO daily • PO • daily
    trigger: Tier 2 add-on
    FIDELIO + FIGARO 2020/2021
  3. 3. GLP-1 RA if T2DM + CV/renal residual risk
    Semaglutide 1 mg SC weekly or liraglutide 1.8 mg SC daily • SC • weekly or daily
    trigger: Tier 3 add-on
    FLOW 2024 + LEADER 2016
  4. 4. Glycemic optimization (metformin + others)
    Per ADA + KDIGO • PO + SC • per regimen
    trigger: A1c gap
    ADA + KDIGO 2022

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Rising UACR ≥30 mg/g in patient with diabetes (KDIGO 2022 Diabetes-in-CKD); Declining eGFR + diabetes (KDIGO 2022 Diabetes-in-CKD); Diabetic kidney disease on problem list (KDIGO 2022).

Objective

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

Assessment

**Diabetic Kidney Disease (DKD)** (renal.diabetic-nephropathy.v1).
Phenotype framing: Classic DKD (albuminuric) / non-albuminuric DKD / biopsy-discordant NDD / overlap with HTN / GN / amyloid (KDIGO 2022)
Scope: Confirm DKD via DM + albuminuria/eGFR-decline + retinopathy support; classify KDIGO heat-map stage (KDIGO 2022 Diabetes-in-CKD)

No severity triggers fired against current inputs.

Plan

Regimen axis: **DKD tier ladder — Tier 1 RAS + SGLT2i + statin + BP/A1c (foundational) → Tier 2 finerenone (FIDELIO + FIGARO) → Tier 3 GLP-1 RA (LEADER + FLOW) → Tier 4 transplant/RRT planning (KDIGO 2022 Diabetes-in-CKD)** — step "Tier 1 — Foundational therapy (always — RAS + SGLT2i + statin + BP/A1c + lifestyle)".
1. lisinopril 10 mg PO daily, titrate to max tolerated (40 mg) PO daily (acei, first line) — KDIGO 2022 — max-tolerated ACEi/ARB; titrate to BP <130/80 + minimize albuminuria
2. losartan 50-100 mg PO daily, titrate to max tolerated PO daily (arb, first line) — KDIGO 2022 — ARB equivalent first-line if ACEi cough/angioedema
3. empagliflozin 10 mg PO daily PO daily (sglt2i, first line) — EMPA-KIDNEY 2023 PMID 36331190 — empagliflozin reduces CKD progression + CV death; KDIGO 2022 Diabetes-in-CKD foundational
4. dapagliflozin 10 mg PO daily PO daily (sglt2i, first line) — DAPA-CKD Heerspink NEJM 2020 — alternative SGLT2i; KDIGO 2022
5. canagliflozin 100 mg PO daily, titrate to 300 mg if eGFR ≥60 PO daily (sglt2i, first line) — CREDENCE Perkovic NEJM 2019 — canagliflozin in DKD with renal primary endpoint
6. atorvastatin 40 mg PO daily (high-intensity if ASCVD or risk) PO daily (statin, first line) — ACC/AHA Lipid 2026 — high-intensity statin for DKD + ASCVD risk reduction

Setting playbook (outpatient) — DKD primary management — tier ladder execution + KDIGO heat-map tracking + transplant + RRT planning + multidisciplinary co-management (KDIGO 2022)
7. Tier 1 RAS + SGLT2i + statin + BP + A1c titration Up-titrate q2-4 wk to target PO daily — Tier 1 optimization (KDIGO 2022)
8. Finerenone if albuminuric + eGFR ≥25 + K+ ≤4.8 10-20 mg PO daily PO daily — Tier 2 add-on (FIDELIO + FIGARO 2020/2021)
9. GLP-1 RA if T2DM + CV/renal residual risk Semaglutide 1 mg SC weekly or liraglutide 1.8 mg SC daily SC weekly or daily — Tier 3 add-on (FLOW 2024 + LEADER 2016)
10. Glycemic optimization (metformin + others) Per ADA + KDIGO PO + SC per regimen — A1c gap (ADA + KDIGO 2022)

Non-pharmacologic actions:
- Cardiology + endocrinology + ophthalmology + nephrology co-management (KDIGO 2022)
- Vaccinations per ACIP 2026 (flu, pneumococcal, COVID-19, RSV, shingles, HBV)
- Nutrition + low-Na + protein 0.8 g/kg/d counseling (KDIGO 2022)
- Transplant referral evaluation at eGFR <30 (G4) (KDIGO 2022)
- AVF placement 6 months pre-anticipated RRT (KDOQI 2019)
- Pre-RRT shared decision-making — dialysis vs conservative (KDIGO 2015)
- Smoking cessation + cardiac rehab (Lipid 2026)
- CGM education for select patients (ADA + KDIGO 2022)

AVOID / contraindication checks:
- Pregnancy_discontinue_acei_arb_sglt2i_finerenone (KDIGO 2022)
- K_above_5.5_reduce_finerenone_mra_ras (FIDELIO 2020)
- Sglt2i_egfr_lt_20_hold_or_dose adjust (EMPA KIDNEY 2023)
- Sglt2i_hold_during_acute_illness_sick_day_rule (KDIGO 2022)
- Glp1_ra_avoid_in_personal_or_family_mtc_or_men2 (FDA labeling)
- No_nsaids_in_dkd (KDIGO 2022)
- Contrast_pre_hydration_per_kdigo_2024 (KDIGO 2024)

Monitoring

Regimen monitoring:
- UACR + eGFR + K+ + BP q3-6 mo (KDIGO 2022)
- A1c q3-6 mo (KDIGO 2022)
- K+ q1-2 wk after finerenone or RAS titration (FIDELIO 2020)
- Fundoscopic eval annually (ADA + KDIGO 2022)
- eGFR slope quarterly — flag >5/y as rapid progressor (KDIGO 2022)
- Lipid panel + statin tolerance annual (ACC/AHA Lipid 2026)

Setting (outpatient) monitoring:
- BMP + UACR + A1c q3-6 mo (KDIGO 2022)
- eGFR slope quarterly (KDIGO 2022)
- K+ q1-2 wk after finerenone/RAS titration; q3-6 mo stable (FIDELIO 2020)
- Fundoscopic annually (ADA + KDIGO 2022)
- Lipid panel annually (Lipid 2026)

Follow-up plan: q3-6 mo nephrology + endocrinology; transplant evaluation at G4 (eGFR <30); AVF placement 6 mo pre-RRT; pre-RRT immunization + nutrition + psychosocial (KDIGO 2022)
- Close-out criterion: Long-term plan documented (KDIGO 2022)

Monitoring phase: UACR + eGFR + K+ + BP + A1c q3-6 mo; nephrology q3-6 mo; ophthalmology annually (KDIGO 2022)

Disposition

Current setting: outpatient — DKD primary management — tier ladder execution + KDIGO heat-map tracking + transplant + RRT planning + multidisciplinary co-management (KDIGO 2022)

Disposition criteria:
- Continue nephrology + endocrinology q3-6 mo if stable (KDIGO 2022)
- Admit if AKI-on-CKD / nephrotic flare / biopsy needed (KDIGO 2022)

Escalation triggers (move to higher acuity):
- Rising Cr >30% on RAS → reduce dose; rule out volume loss + nephrotoxin (KDIGO 2022)
- K+ >5.5 → reduce MRA/finerenone/RAS; binder (patiromer/SZC) if persistent (KDIGO 2022)
- Atypical features (hematuria + RBC casts, low complement, no retinopathy long DM) → biopsy (KDIGO 2022)
- Rapid eGFR decline >5/y → workup for accelerated DKD or NDD (KDIGO 2022)
- eGFR <30 → transplant evaluation + AVF planning + pre-RRT education (KDIGO 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Rapid progressor — eGFR decline >5 mL/min/y; consider biopsy for accelerated DKD or NDD; intensify tier ladder + transplant evaluation early (KDIGO 2022)
- [SEVERE] Biopsy-discordant non-diabetic kidney disease — atypical features (rapid Cr rise, hematuria + RBC casts, low C3/C4, no retinopathy with long DM, nephrotic-range new onset) → biopsy (KDIGO 2022)
- [SEVERE] DKD with concurrent ASCVD — secondary prevention; high-intensity statin + ezetimibe + PCSK9i if needed; SGLT2i + GLP-1 RA add-on (ACC/AHA Lipid 2026; KDIGO 2022)

Citations

- KDIGO 2022 Diabetes Management in CKD + RENAAL/IDNT (RAAS) + SGLT2i (CREDENCE, DAPA-CKD) + finerenone (FIDELIO-DKD, FIGARO-DKD) + GLP-1 RA (FLOW, LEADER) [PMID:36272764](https://pubmed.ncbi.nlm.nih.gov/36272764/)
- Cited evidence (PMID 11565518) [PMID:11565518](https://pubmed.ncbi.nlm.nih.gov/11565518/)
- Cited evidence (PMID 11565517) [PMID:11565517](https://pubmed.ncbi.nlm.nih.gov/11565517/)
- Cited evidence (PMID 30990260) [PMID:30990260](https://pubmed.ncbi.nlm.nih.gov/30990260/)
- Cited evidence (PMID 33264825) [PMID:33264825](https://pubmed.ncbi.nlm.nih.gov/33264825/)

Last reconciled with current guidelines: 2026-05-22.
References
  • KDIGO 2022 Diabetes Management in CKD + RENAAL/IDNT (RAAS) + SGLT2i (CREDENCE, DAPA-CKD) + finerenone (FIDELIO-DKD, FIGARO-DKD) + GLP-1 RA (FLOW, LEADER) — PMID:36272764
  • Cited evidence (PMID 11565518) — PMID:11565518
  • Cited evidence (PMID 11565517) — PMID:11565517
  • Cited evidence (PMID 30990260) — PMID:30990260
  • Cited evidence (PMID 33264825) — PMID:33264825