"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

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.

Hospital-acquired nephrotoxic exposures in the precipitation of acute kidney injury – A case series analysis and a call for more preventative nephrology practices

“…However, the addition of celecoxib, a Cox II inhibitor to his outpatient medications, lisinopril and hydrochlorothiazide, completed the circle of "triple whammy" exposure, thus raising the ante for the occurrence of nephrotoxicity (22)(23)(24)(25)(26). This was then further exacerbated by the super-imposition of peri-operative hypotension, thus constituting the "quadruple whammy' syndrome that we first described in the English literature earlier in 2013 and 2014 (27)(28)(29). Obviously, we would posit, that whereas the ACE inhibitor was withheld for 3-5 days before the elective right hip arthroplasty (30), and whereas the patient had received an alternative analgesic other than a NSAID of a Cox II inhibitor, and whereas intraoperative hypotension was avoided in the operating room, the patient would have experienced a smoother postoperative course, no AKI, reduced hospital stay and significantly reduced healthcare costs.…”

“…To further exacerbate this scenario, the patient during the anterior resection of the rectal mass experienced significant intraoperative hypotension, a factor that has now been acknowledged to be a neglected yet potent factor in the pathogenesis of post-operative AKI (12)(13)(14)(15)(16). We dubbed this phenomenon as the previously unrecognized syndrome of "quadruple whammy" (27)(28)(29). We would argue that a pre-emptive withholding of the ACE inhibitor before the elective anterior resection of the rectal mass (30), the avoidance of the NSAID agent ketorolac, and a more aggressive prevention of intraoperative hypotension would have obviated the degree of AKI, a much shortened hospital stay and of course reduced healthcare costs.…”

Intervención farmacéutica para reducir el riesgo de iatrogenia asociada a la combinación triple whammy

“…Camin et al detectaron que, en un 67% de los casos, el FRA se había desencadenado por la situación clínica del paciente en los días previos (fiebre, diarrea o vómitos), lo que algunos autores han definido como quadruple whammy 11 , que incluye la combinación TW y la situación clínica del paciente, como deshidratación o una intervención quirúrgica. Consideramos que se debe tener presente el riesgo asociado a la combinación TW, sobre todo en pacientes ancianos y polimedicados, en los que en muchos casos no hay una indicación para un consumo crónico, y que se debe informar a los profesionales y a los pacientes para evitar el consumo en situaciones clínicas que puedan provocar un FRA.…”

Chronic Kidney Disease: A Life Course Health Development Perspective

“…There is a clear impact of over-the-counter medications alone and in combination with prescription medications on the development of acute kidney injury or worsening of CKD. (Onuigbo and Agbasi 2014) In particular, the geriatric population may be at very high risk for this effect (Mizokami and Mizuno 2015). Across the life span, medications can have a significant impact on the development of acute kidney injury.…”