Self-induced Anuria with Diclofenac: An Interesting Case of “Quadruple Whammy” Acute Kidney Injury

Abstract

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are a group of drugs widely prescribed and used worldwide. Patients taking NSAIDs, including diclofenac, should be aware of its potential nephrotoxic effects. However, the rapid onset of acute kidney injury (AKI) after a single dose of diclofenac is considered a very rare side effect. Case Presentation: We present a 66-year-old woman with habitual self-induced anuria with the chief complaint of shoulder pain due to falling down. The patient presented with various co-morbid conditions, including hypertension, type 2 diabetes, tricuspid valve repair, and aortic valve replacement. She rapidly developed anuria after receiving a single dose of diclofenac over the previous two days of admission. Creatinine and BUN exhibited a significant rise in laboratory tests. During hospitalization, the consumption of NSAIDs was prohibited and losartan and furosemide were discontinued. Moreover, phenacetin was used to relieve pain instead. Luckily, after two days of hospitalization, urine output returned to normal levels. Additionally, creatinine and BUN levels gradually decreased to baseline values. Conclusion: To the best of our knowledge, we described a rare case of diclofenac-induced AKI presenting with anuria, a complete cessation of urine flow, in a patient with no previous kidney complications. This case can be explained by the phenomenon known as “quadruple Whammy,” which involves the concurrent use of NSAIDs, ARBs, and diuretics in the setting of hypovolemia.