Mineralocorticoid receptor antagonists (MRAs), such as spironolactone and eplenerone, might be safe and effective for select dialysis patients with heart failure and reduced ejection fraction (HFrEF), according to the authors of a new review article.

The potential benefits from use of MRAs, which are potassium-sparing diuretics, in patients with end-stage kidney disease (ESKD) include blood pressure control, regression of left ventricular hypertrophy, decreased arterial calcification and vascular disease, reduction in atrial fibrillation, and decreased hospitalization and death, Gregg M. Lanier, MD, of Westchester Medical Center in Valhalla, New York, and colleagues stated in Cardiology in Review.

In 8 small studies of patients on peritoneal dialysis (PD) with or without heart failure, spironolactone 25 mg or 50 mg daily appeared safe. Few significant adverse effects, and rarely hyperkalemia, occurred over 4 weeks to 2 years. MRA use appeared to improve ejection fraction and may help preserve the peritoneal membrane.

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In 17 small studies and case reports of hemodialysis patients (HD) taking spironolactone (variably dosed) or eplenerone (25 to 50 mg/d), there were some indications of cardiovascular benefit such as reduced left ventricular mass or vascular calcification. Hyperkalemia occasionally occurred leading some to discontinue their medication.

More definitive data may be forthcoming. ALCHEMIST (Aldosterone Antagonist Hemodialysis Survival Trial), which includes 825 HD patients (some with heart failure), is investigating whether spironolactone will reduce the composite endpoints of nonfatal myocardial infarction and stroke, heart failure hospitalization, cardiovascular death, time to all-cause mortality, time to cardiovascular events, and hyperkalemia.

“Close potassium monitoring may mitigate the risk for hyperkalemia in [ESKD] patients with HFrEF on hemodialysis and PD, while allowing them possible cardiovascular benefits from these medications,” Dr Lanier and colleagues stated. “The majority of available studies in [ESKD] patients, with or without HF, with the administration of MRAs show safety, especially in PD patients.”

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Bhinder J, Patibandla S, Gupta CA, et al. Mineralocorticoid receptor antagonist use in heart failure with reduced ejection fraction and end-stage renal disease patients on dialysis: A literature review. Cardiol Rev. 2020;28:107-115. doi: 10.1097/CRD.0000000000000286