Should Spironolactone (aldosterone antagonist) be stopped in a cirrhotic patient with impaired renal function (eGFR (estimated Glomerular Filtration Rate) of 54)?

From the Guidelines

Spironolactone should be used with caution but does not necessarily need to be stopped in a cirrhotic patient with an eGFR of 54. This mild renal impairment (Stage 3a CKD) requires close monitoring rather than automatic discontinuation. When managing cirrhotic patients with ascites, spironolactone remains an important medication for controlling fluid accumulation by blocking aldosterone's sodium-retaining effects, as supported by the guidelines from the American Association for the Study of Liver Diseases 1. For this patient, consider reducing the spironolactone dose (perhaps to 50-100 mg daily instead of higher doses) and implementing more frequent monitoring of serum potassium and creatinine levels (every 1-2 weeks initially). Watch carefully for hyperkalemia, which is the primary concern with spironolactone in renal impairment. If the patient's renal function worsens (eGFR dropping below 30) or if hyperkalemia develops (potassium >5.5 mEq/L), the medication should be discontinued, as advised in the European Society of Cardiology guidelines 1. The risk-benefit assessment must consider the severity of ascites and the patient's overall clinical picture, as poorly controlled ascites can itself contribute to renal dysfunction through increased intra-abdominal pressure and reduced renal perfusion.

Some key points to consider in the management of ascites in cirrhotic patients include:

• The use of diuretics, with spironolactone being the primary choice due to its effectiveness in blocking aldosterone's sodium-retaining effects 1.
• Monitoring for potential side effects such as hyperkalemia and worsening renal function, and adjusting the dose of spironolactone accordingly 1.
• The importance of considering the patient's overall clinical picture, including the severity of ascites and the presence of any other complications, when making decisions about diuretic therapy 1.
• The potential benefits of combining spironolactone with other diuretics, such as furosemide, to achieve optimal diuresis and minimize the risk of complications 1.

Overall, the management of ascites in cirrhotic patients requires careful consideration of the potential benefits and risks of diuretic therapy, as well as close monitoring of the patient's condition to minimize the risk of complications.

From the FDA Drug Label

Spironolactone is substantially excreted by the kidney, and the risk of adverse reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, monitor renal function. Patients with renal impairment are at increased risk of hyperkalemia. Monitor potassium closely. In patients with cirrhosis, start with lowest initial dose and titrate slowly

The patient has an eGFR of 54, indicating impaired renal function. Renal impairment increases the risk of hyperkalemia and adverse reactions to spironolactone.

• The drug label recommends monitoring renal function and potassium levels closely in patients with impaired renal function.
• It also advises starting with the lowest initial dose and titrating slowly in patients with cirrhosis. Considering the patient's cirrhosis and impaired renal function, it is recommended to exercise caution and consider stopping or adjusting the spironolactone dose to minimize the risk of adverse reactions, particularly hyperkalemia 2 2.

From the Research

Impaired Renal Function in Cirrhotic Patients

• The estimated Glomerular Filtration Rate (eGFR) of 54 in a cirrhotic patient indicates impaired renal function 3.
• In cirrhotic patients, the reliability of formulas that estimate renal function has not been properly quantified, and the agreement between estimated and measured glomerular filtration rate is poor 3.

Use of Spironolactone in Cirrhotic Patients

• Spironolactone is commonly used in the treatment of cirrhotic patients with ascites, as it helps to eliminate ascites by increasing sodium excretion 4, 5, 6.
• The recommended initial dose of spironolactone is 100-200 mg/d, and the usual maximum dose is 400 mg/d 5.
• Spironolactone is more effective than furosemide in the elimination of ascites in cirrhotic patients, but it can cause side effects such as gynecomastia and hyperkalemia 4, 7.

Management of Ascites in Cirrhotic Patients with Impaired Renal Function

• The management of ascites in cirrhotic patients with impaired renal function requires careful consideration of the patient's renal function and the potential side effects of diuretics 5, 6.
• Therapeutic paracentesis associated with intravenous albumin infusion is the treatment of choice for cirrhotic patients with tense ascites, and diuretics should be given after the elimination of ascites to avoid reaccumulation of the abdominal fluid 6.
• In patients with refractory ascites, treatment options include serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), or peritoneovenous shunt, and liver transplantation 5.

Decision to Stop Spironolactone

• There is no clear evidence to suggest that spironolactone should be stopped in a cirrhotic patient with an eGFR of 54, but the patient's renal function and potential side effects should be closely monitored 4, 5, 6, 3, 7.
• The decision to stop spironolactone should be based on the individual patient's response to treatment and the presence of any adverse effects, rather than solely on the eGFR value 7.