gQuadruple whammyh- A preventable newly described syndrome of post.operative AKI in CKD II and CKD III patients on combination gTriple whammyh medications: A Mayo Clinic Health System, Eau Claire, Wisconsin experience

Abstract

Background: The potential combination of diuretics..angiotensin.converting enzyme inhibitors..Non.steroidal anti-inflammatory drugs (diuretics-ACEIs-NSAIDs), the so.called etriple whammyf, to produce clinically significant
nephrotoxicity in chronic kidney disease (CKD) is often unrecognized. In 2013, in the British Medical Journal, we described accelerated  post-operative acute kidney injury (AKI) in CKD patients concurrently on etriple whammyf medications, a new syndrome that we aptly named equadruple whammyf.

Materials and Methods: Two case reports.

Results: I.A 59-year-old Caucasian male, hypertensive CKD III, serum creatinine (SCr) 1.42 mg/dL, developed accelerated oliguric AKI after
elective right nephrectomy.Outpatient medications included Lisinopril-Hydrochlorothiazide and Nabumetone (NSAID). SCr rapidly more than doubled with metabolic acidosis and hyperkalemia within 24 hours, peaking at 4.02 mg/dL. eTriple whammyf medications were promptly stopped and the hypotension was corrected. SCr was 1.64 mg/dL and stable, after
three months. II. A 46-year-old Caucasian male, hypertensive CKD II, SCr 1.21 mg/dL, developed accelerated AKI after elective right hip arthroplasty. Outpatient medications included Lisinopril and Hydrochlorothiazide.  Celecoxib (200 mg) was given pre.operatively. Within 36 hours, SCr rapidly more than doubled to 2.58 mg/dL, with metabolic acidosis. eTriple whammyf medications were promptly stopped and the hypotension was corrected. SCr was 0.99 mg/dL, and stable, after one month.

Conclusion: We have described two cases of preventable accelerated AKI following post-operative hypotension in CKD patients concurrently on etriple whammyf medications. We dubbed this new syndrome gQuadruple Whammyh. It is not uncommon. eRenopreventionf, the pre-emptive withholding of (potentially nephrotoxic) medications, including etriple whammyf medications, pre-operatively, in CKD patients, together with the simultaneous avoidance of peri.operative hypotension would help reduce, if not eliminate such AKI - a call for more pharmacovigilance.

Key words: Angiotensin converting enzyme inhibitors, acute kidney injury, chronic kidney disease, diuretics, Non-steroidal anti-infl ammatory drugs, post.operative hypotension, quadruple whammy, serum creatinine, triple whammy