Spironolactone to treat hypertension in end-stage renal disease : analysis of effectiveness and safety
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Purpose: Cardiovascular events and complications are the major causes of death in patients with end-stage renal disease (ESRD)¹⁻³. Antihypertensive agents that block the renin-angiotensin-aldosterone system (RAAS) are considered first-line therapy in patients with ESRD as these patients have a propensity for RAAS overactivation⁴⁻⁷. Studies show that aldosterone receptor blockade reduces BP in patients with chronic kidney disease (CKD) and helps prevent negative outcomes from continued renal cellular damage⁸⁻¹⁰. Spironolactone, an aldosterone antagonist, has the potential to provoke hyperkalemia. Consequently, current guidelines do not recommend spironolactone to manage hypertension in ESRD because of this risk⁶⁻⁷. Our primary objectives were to determine the change in BP and serum potassium levels following spironolactone use. Methods: This study was a retrospective, pre-post cohort study in ESRD patients with difficult-to-control BP receiving HD. Patients prescribed spironolactone (25 mg to 50 mg) between January 2009 and January 2013 were identified using an e-prescribing record from three HD clinics in San Antonio, TX. Patients were included if they were prescribed spironolactone as 'add-on' therapy to control BP for at least 8 weeks. Results: Seventy patients were evaluated and the majority of them were overweight, diabetic, Hispanic females with a mean 65 years of age. Mean SBP and DBP decreased from baseline to week 8 [-20.74 mmHg (p < 0.0001) and -9.7 mmHg (p < 0.0426), respectively]. Mean serum potassium levels increased by an average of 0.18 mEq/L (4.5 mEq/L to 4.68 mEq/L, p = 0.09). Data analysis revealed that only 9 of 70 patients had a serum potassium level > 5.5 mEq/L at week 8. There were no adverse cardiac events reported as a result of these potassium concentrations. A two-fold decrease in SBP was seen in patients with a body mass index (BMI) > 25 kg/m² compared to patients with a BMI of ≤ 25 kg/m². At the end of the study, 23 patients (33%) achieved the goal BP for healthy adults of < 140/90 mmHg. Conclusion: These findings demonstrated that using spironolactone use in ESRD patients receiving HD can be effective and safe.