Is Spironolactone (Aldactone) effective for Chronic Kidney Disease (CKD) stage 2 with Impaired Renal Function?

From the Guidelines

Spironolactone is not recommended for stage 2 kidney disease without careful medical supervision due to the risk of hyperkalemia and potential worsening of kidney function. The use of spironolactone in patients with chronic kidney disease (CKD) is a complex issue, as it can be beneficial for certain conditions like resistant hypertension or heart failure, but it also poses significant risks [ 1 ]. In stage 2 CKD, where kidney function is mildly decreased (GFR between 60-89 mL/min), the kidneys already have reduced ability to excrete potassium, making the use of spironolactone potentially hazardous [ 1 ].

Key Considerations

• The kidneys' reduced ability to excrete potassium in stage 2 CKD increases the risk of hyperkalemia with spironolactone use.
• Spironolactone is a potassium-sparing diuretic and aldosterone antagonist, which can contribute to hypertension and heart failure, but its benefits must be weighed against the risks in CKD patients.
• Close monitoring of potassium levels and kidney function is necessary if spironolactone is prescribed, with starting doses typically lower (12.5-25 mg daily) than those used in patients with normal kidney function.
• Patients taking spironolactone should avoid high-potassium foods and other potassium-sparing medications to minimize the risk of hyperkalemia.

Recommendations

• Any decision to use spironolactone in kidney disease should be made by a nephrologist who can weigh the potential benefits against the risks for the specific situation [ 1 ].
• Renin-angiotensin-aldosterone system (RAS) inhibitors, such as ACE inhibitors or ARBs, are preferred for the treatment of hypertension in patients with diabetes and CKD, due to their proven benefits in preventing CKD progression [ 1 ].
• The use of mineralocorticoid receptor antagonists like spironolactone should be considered with caution and under close supervision in patients with CKD, due to the potential risks and the availability of alternative treatments [ 1 ].

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.

The use of spironolactone in patients with stage 2 kidney disease may be associated with an increased risk of adverse reactions, including hyperkalemia. Monitoring of renal function and potassium levels is recommended. However, the FDA drug label does not provide direct guidance on the use of spironolactone in stage 2 kidney disease. 2 2

From the Research

Efficacy of Spironolactone in Stage 2 Kidney Disease

• Spironolactone has been shown to reduce albuminuria in patients with chronic kidney disease (CKD) and type 2 diabetes 3.
• A study found that low-dose spironolactone (12.5 mg/d) reduced the risk of hyperkalemia while maintaining its effect on reducing albuminemia in patients with CKD and type 2 diabetes 3.
• Another study demonstrated that low-dose spironolactone (25-50 mg/day) provided a significant additive blood pressure reduction in CKD patients (stage 2 and 3) with resistant hypertension 4.

Safety and Tolerability of Spironolactone

• The use of spironolactone in patients with CKD and heart failure has been shown to be safe and effective, but requires close monitoring to avoid hyperkalemia 5, 6.
• A study found that spironolactone may be safe to initiate in hospitalized patients with heart failure and CKD, but appropriateness of therapy must be assessed upon admission to the hospital 6.
• However, combined therapy with angiotensin-converting enzyme inhibitors and spironolactone can increase the risk of life-threatening hyperkalemia, particularly in patients with renal insufficiency, diabetes, and older age 7.

Considerations for Stage 2 Kidney Disease

• Patients with stage 2 kidney disease may benefit from spironolactone therapy, but should be closely monitored for hyperkalemia and other potential adverse effects 3, 4.
• The use of low-dose spironolactone (12.5-25 mg/day) may be a suitable option for patients with stage 2 kidney disease, as it has been shown to reduce the risk of hyperkalemia while maintaining its therapeutic effects 3, 4.