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Triple Whammy AKI — ESENeph MCQ

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ModerateAcute Kidney InjuryTriple Whammy AKIESENeph

A 55-year-old woman develops AKI after starting Naproxen for back pain. She is on Ramipril and Bendroflumethiazide. Her creatinine rises from 100 to 210 umol/L. What mechanism best explains this AKI?

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Correct answer: A — Triple whammy effect: NSAIDs constrict afferent arteriole, ACEi dilates efferent arteriole, diuretic causes volume depletion – combined haemodynamic AKI

The 'triple whammy' of NSAID + ACEi/ARB + diuretic is a well-recognised cause of haemodynamic AKI. NSAIDs inhibit prostaglandin-mediated afferent arteriolar vasodilation (constricting the afferent arteriole). ACEi/ARBs dilate the efferent arteriole. Diuretics cause intravascular volume depletion. The combination severely reduces intraglomerular pressure and GFR. Management involves stopping the NSAID, withholding the diuretic, and potentially temporarily holding the ACEi until renal function recovers.

Reference: NICE AKI Pathway 2019; Lapi et al 2013 – Triple Whammy, BMJ