title: Acute kidney injury secondary to a combination of renin-angiotensin system inhibitors, diuretics and NSAIDS: "The Triple Whammy".
abstract: BACKGROUND
  Renin-angiotensin system inhibitors (ACEI/ARB-II), diuretics and NSAIDs, a combination known as "Triple Whammy", can result in decreased glomerular filtration rate (GFR) and acute kidney injury (AKI). Objectives: To describe the incidence of AKI for each drug type and their combinations. To define the profile of patients admitted for drug-related AKI secondary to Triple Whammy drugs (AKITW), with an assessment of costs and mortality.
  
  
  METHODS
  A retrospective observational 15-month study developed in three stages: - First: a cross-sectional stage to identify and describe hospitalizations due to AKITW. - Second: a follow-up stage of an outpatient cohort consuming these drugs (15,307 subjects). - Third: a cohort stage to assess costs and mortality, which compared 62 hospitalized patients with AKITW and 62 without AKI, paired by medical specialty, sex, age and comorbidity according to their Clinical Risk Groups.
  
  
  RESULTS
  There were 85 hospitalization episodes due to AKITW, and 78% of patients were over the age of 70. The incidence of AKITW in the population was 3.40 cases/1000 users/year (95% CI: 2.59-4.45). By categories, these were: NSAIDs + diuretics 8.99 (95% CI: 3.16-25.3); Triple Whammy 8.82 (95% CI: 4.4-17.3); ACEI/ARB-II + diuretics 6.87 (95% CI: 4.81-9.82); and monotherapy with diuretics 3.31 (95% CI: 1.39-7.85). Mean hospital stay was 7.6 days (SD 6.4), and mean avoidable costs were estimated at €214,604/100,000 inhabitants/year. Mortality during hospitalization and at 12 months was 11.3% and 38.7% respectively, and there were no significant differences when compared with the control group.
  
  
  CONCLUSIONS
  Treatment with ACEI, ARB-II, diuretics and/or NSAIDs shows a high incidence of hospitalization episodes due to AKI; diuretics as monotherapy or dual and triple combination therapy cause the highest incidence. AKITW involves high health care costs and avoidable mortality.
authors: Servicio de Nefrología. Hospital de Palamós. Palamos, Girona (España). Electronic address: rmgarcia@ssibe.cat.
authors: Rosa Maria Garcia
authors: RM
authors: Camin
authors: Servicio de Farmacia, Serveis de Salut Integrats Baix Emporda (SSIBE). Palamós, Girona (España).
authors: Montse
authors: M
authors: Cols
authors: Servicio de Nefrología. Hospital de Palamós. Palamos, Girona (España).
authors: Julio Leonel
authors: JL
authors: Chevarria
authors: Servicio de Nefrología. Hospital de Palamós. Palamos, Girona (España).
authors: Rosa García
authors: RG
authors: Osuna
authors: Grup de recerca en Serveis Sanitaris i Resultats en Salut (GRESSIRES). Serveis de Salut Integrats Baix Emporda (SSIBE). Palamós, Girona (España).
authors: Marc
authors: M
authors: Carreras
authors: Unidad de información asistencial. Serveis de Salut Integrats Baix Emporda (SSIBE). Palamós, Girona (España).
authors: Josep Maria
authors: JM
authors: Lisbona
authors: Grup de recerca en Serveis Sanitaris i Resultats en Salut (GRESSIRES). Serveis de Salut Integrats Baix Emporda (SSIBE). Palamós, Girona (España).
authors: Jordi
authors: J
authors: Coderch
mesh_terms: D058186:Acute Kidney Injury / Q000188:drug therapy* / Q000191:economics / Q000401:mortality; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000009:adverse effects* / Q000493:pharmacokinetics; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects* / Q000493:pharmacokinetics; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects* / Q000493:pharmacokinetics; D003430:Cross-Sectional Studies; D004232:Diuretics / Q000009:adverse effects* / Q000493:pharmacokinetics; D004357:Drug Synergism; D005260:Female; D017721:Hospital Costs; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D012084:Renin-Angiotensin System / Q000187:drug effects; D012189:Retrospective Studies; D013030:Spain
chemical_list: D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D000894:Anti-Inflammatory Agents, Non-Steroidal; D004232:Diuretics
keywords: Acute kidney injury; Agentes antihipertensivos; Agentes antiinflamatorios; Anti-inflammatory agents; Antihypertensive agents; Diuretics; Diuréticos; Drug interactions; Interacciones farmacológicas; Lesión renal aguda