title: "Quadruple whammy"- a preventable newly described syndrome of post-operative AKI in CKD II and CKD III patients on combination "Triple whammy" 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 'triple whammy', 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 'triple whammy' medications, a new syndrome that we aptly named 'quadruple whammy'.
  
  
  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. 'Triple whammy' 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. 'Triple whammy' medications were promptly stopped and the hypotension was corrected. SCr was 0.99 mg/dL, and stable, after one month.
  
  
  CONCLUSIONS
  We have described two cases of preventable accelerated AKI following post-operative hypotension in CKD patients concurrently on 'triple whammy' medications. We dubbed this new syndrome "Quadruple Whammy". It is not uncommon. 'Renoprevention', the pre-emptive withholding of (potentially nephrotoxic) medications, including 'triple whammy' 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.
authors.affiliation: Mayo Clinic College of Medicine, Rochester, Minnesota; Department of Nephrology, Mayo Clinic Health System, Eau Claire, Wisconsin, USA, .
authors.forename: M A
authors.initials: MA
authors.lastname: Onuigbo
authors.forename: N
authors.initials: N
authors.lastname: Agbasi
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology*; D000959:Antihypertensive Agents / Q000008:administration & dosage / Q000009:adverse effects*; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects; D002074:Butanones / Q000008:administration & dosage / Q000009:adverse effects; D000068579:Celecoxib; D052246:Cyclooxygenase 2 Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D004338:Drug Combinations; D004359:Drug Therapy, Combination / Q000009:adverse effects; D006801:Humans; D006852:Hydrochlorothiazide / Q000008:administration & dosage / Q000009:adverse effects*; D017706:Lisinopril / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D000077430:Nabumetone; D009392:Nephrectomy / Q000009:adverse effects; D011183:Postoperative Complications; D011720:Pyrazoles / Q000008:administration & dosage / Q000009:adverse effects; D051436:Renal Insufficiency, Chronic / Q000150:complications*; D013449:Sulfonamides / Q000008:administration & dosage / Q000009:adverse effects; D013577:Syndrome; D014922:Wisconsin
chemical_list: D000959:Antihypertensive Agents; D002074:Butanones; D052246:Cyclooxygenase 2 Inhibitors; D004338:Drug Combinations; D011720:Pyrazoles; D013449:Sulfonamides; C091365:hydrochlorothiazide, lisinopril drug combination; D006852:Hydrochlorothiazide; D017706:Lisinopril; D000068579:Celecoxib; D000077430:Nabumetone