Can spironolactone be used in patients undergoing Hemodialysis (HD)?

Use of Spironolactone in Hemodialysis Patients

Spironolactone can be used cautiously in hemodialysis patients at low doses (25 mg/day or 25 mg three times weekly after dialysis) with close monitoring of potassium levels, despite traditional contraindications in renal failure.

Evidence for Safety in Hemodialysis

The traditional concern with spironolactone in end-stage renal disease (ESRD) has been the risk of life-threatening hyperkalemia. However, several small studies have demonstrated that low-dose spironolactone may be safely administered to hemodialysis patients:

• Multiple prospective trials have shown that spironolactone use in hemodialysis patients did not result in significantly higher rates of hyperkalemia compared to control groups 1, 2
• A 2009 study of 61 oligoanuric hemodialysis patients receiving 25 mg/day of spironolactone for 6 months found no patients developed potassium levels >6.8 mEq/L or required ion exchange resin therapy 1
• Another study demonstrated that 25 mg spironolactone administered three times weekly after dialysis did not significantly change mean serum potassium levels 3

Potential Benefits in Hemodialysis Patients

Spironolactone may provide cardiovascular benefits in hemodialysis patients:

• Improved ejection fraction (6.2 ± 1.64% increase vs. 0.83 ± 4.9% in placebo group, p=0.046) 4
• Decreased left ventricular mass (-8.4 ± 4.72 vs. +3 ± 7.97 in placebo group, p=0.021) 4
• Potential reduction in cardiovascular mortality, similar to benefits seen in non-dialysis heart failure patients 1

Recommended Protocol for Use in Hemodialysis

1. Patient Selection:

   • Stable hemodialysis patients
   • Baseline serum potassium <5.0 mEq/L
   • No missed dialysis sessions
   • Preferably with heart failure or cardiovascular indications

2. Dosing:

   • Initial dose: 12.5-25 mg after each dialysis session OR 25 mg daily
   • Maximum dose: 25 mg three times weekly or 25 mg daily

3. Monitoring:

   • Check serum potassium before every hemodialysis session for first month
   • Monitor potassium at least monthly thereafter
   • Discontinue if potassium exceeds 6.0 mEq/L

Important Precautions

• Risk of hyperkalemia: While generally safe in studies, individual cases of severe hyperkalemia have occurred 5
• Patient compliance: Studies showing safety involved compliant patients who did not miss dialysis sessions
• Concomitant medications: Use extra caution with ACE inhibitors or ARBs 6
• Dietary factors: Patients should avoid high potassium foods and supplements 6

Common Pitfalls to Avoid

1. Missing the contraindication in FDA labeling: The FDA label notes that spironolactone is substantially excreted by the kidney, and risk of adverse reactions may be greater in patients with impaired renal function 7

2. Inadequate monitoring: Failure to check potassium levels regularly can lead to undetected hyperkalemia

3. Not adjusting other medications: Potassium supplements should be discontinued and other medications that can raise potassium should be used cautiously 6

4. Continuing spironolactone when dialysis is missed: Patients who miss dialysis sessions should temporarily discontinue spironolactone until dialysis is resumed

While the ACC/AHA guidelines recommend avoiding aldosterone antagonists when eGFR is <30 mL/min 6, the emerging research suggests that with proper patient selection and close monitoring, spironolactone can be used safely in the hemodialysis population where kidney function is already absent and potassium removal occurs regularly through dialysis.