Spironolactone (Aldactone) Should Be Used, Not Finerenone, in Hepatorenal Syndrome with Refractory Ascites
Spironolactone is the established mineralocorticoid receptor antagonist for managing ascites in cirrhosis, while finerenone has no role in hepatorenal syndrome or cirrhotic ascites management. Finerenone is a non-steroidal mineralocorticoid receptor antagonist approved exclusively for diabetic kidney disease in the context of heart failure, not liver disease 1.
Why Spironolactone Is the Standard of Care
All major hepatology guidelines recommend spironolactone as the cornerstone diuretic for cirrhotic ascites, including in patients with hepatorenal syndrome. 1, 2, 3
Guideline-Directed Therapy for Hepatorenal Syndrome with Ascites
For refractory ascites in hepatorenal syndrome, combination therapy with spironolactone (100-400 mg/day) plus furosemide (40-160 mg/day) is recommended, maintaining a 100:40 mg ratio to preserve normokalemia 1, 2, 3.
The primary treatment for hepatorenal syndrome itself is vasoconstrictors (terlipressin, noradrenaline, or midodrine/octreotide) plus albumin, not mineralocorticoid receptor antagonists alone 4, 5.
Diuretics in hepatorenal syndrome must be used cautiously and often require dose reduction or temporary discontinuation when serum creatinine rises >2.0 mg/dL or increases by >0.3 mg/dL within 48 hours 1, 6.
Critical Monitoring in This High-Risk Population
Patients with hepatorenal syndrome require intensive monitoring of serum creatinine, sodium, and potassium every 3-5 days during diuretic therapy 2, 6.
Discontinue spironolactone immediately if serum potassium exceeds 6.0 mmol/L or if severe hyponatremia (<120-125 mmol/L) develops 1, 3, 6.
Stop all diuretics if progressive renal failure, worsening hepatic encephalopathy, or severe muscle cramps occur 1, 3.
Why Finerenone Has No Role Here
Finerenone is not indicated for, studied in, or approved for cirrhotic ascites or hepatorenal syndrome. 1
Finerenone's evidence base comes exclusively from heart failure trials (TOPCAT, FIDELIO-DKD, FIGARO-DKD) in patients with preserved or reduced ejection fraction and diabetic kidney disease, populations fundamentally different from cirrhotic patients 1.
The pathophysiology of ascites in cirrhosis—driven by portal hypertension, splanchnic vasodilation, and secondary hyperaldosteronism—requires spironolactone's specific pharmacologic profile 1, 7, 5.
No guideline from EASL, AASLD, or ACG mentions finerenone as a treatment option for cirrhotic ascites 1, 2, 3.
Practical Algorithm for This Patient
Confirm hepatorenal syndrome diagnosis (rising creatinine, oliguria, no response to volume expansion, absence of nephrotoxins) 4, 5.
Initiate vasoconstrictor therapy (terlipressin preferred) plus albumin as the primary treatment for hepatorenal syndrome 4, 5.
For concurrent refractory ascites, use spironolactone 100-200 mg/day plus furosemide 40 mg/day, adjusting every 3-5 days based on response and renal function 2, 3.
If serum creatinine worsens or exceeds 2.0 mg/dL, temporarily hold diuretics and focus on vasoconstrictor/albumin therapy 1, 6.
Consider large-volume paracentesis with albumin (8 g/L removed) for symptomatic relief while optimizing medical therapy 1, 2.
Evaluate urgently for liver transplantation, as hepatorenal syndrome carries a dismal prognosis without transplant 7, 8, 5.
Common Pitfalls to Avoid
Do not use finerenone as a substitute for spironolactone in cirrhotic patients—there is zero evidence supporting this substitution and it represents off-label use in an inappropriate population 1.
Do not continue aggressive diuresis in worsening hepatorenal syndrome—this exacerbates renal hypoperfusion and accelerates kidney injury 1, 5.
Do not delay vasoconstrictor therapy while attempting diuretic optimization—vasoconstrictors plus albumin are the definitive medical treatment for hepatorenal syndrome 4, 5.
Do not forget that spironolactone causes hyperkalemia in 11% of cirrhotic patients, requiring frequent potassium monitoring 1.