Hyperkalemia, congestive heart failure, and aldosterone receptor antagonism

Hyperkalemia is a common occurrence in patients with congestive heart failure, particularly when renal failure coexists. The level of renal function in congestive heart failure is often difficult to ascertain because good measurement tools for estimation of renal function are not available. Serum creatinine values have often been offered as a good gauge of renal function, although in most cases true renal function is appreciably lower than the estimate derived from a specific serum creatinine value. Thus, patients with congestive heart failure very commonly, particularly in the advanced stages of the disease, have moderate renal insufficiency, either due to specific heart failure-related renal perfusion changes or as the result of renal involvement from the same processes having caused the heart failure, as is the case with diabetes. It is in this setting of mild-to-moderate levels of renal failure that therapies, such as angiotensin-converting inhibitors, angiotensin-receptor blockers, and aldosterone-receptor antagonists, are administered either individually or collectively. Each of these drug classes reduces the homeostatic ability to eliminate ingested potassium loads by the renal route and increase the tendency to evolve into a hyperkalemic state. This is noteworthy because aldosterone-receptor antagonists are increasingly considered as important therapies in the long-term management of heart failure. Spironolactone has been employed in this capacity and a new aldosterone-receptor antagonist, eplerenone, will become available in the near future, which further increases the importance of evaluating and treating the hyperkalemia risk in a timely manner.