Aldosterone-receptor antagonism and end-stage renal disease

Blockade of aldosterone effect with either spironolactone or eplerenone is an approach that is being used more frequently in the treatment of hypertension and congestive heart failure; however, sparse information exists pertaining to efficacy or side-effects of this line of treatment for patients with chronic kidney disease and/or end-stage renal disease (ESRD). Hyperkalemia is, by far, the most worrisome complication of therapy with either of these compounds and, not surprisingly, hinders their use in moderate-to-advanced renal failure. However, patients with anuric ESRD should theoretically not be at risk for hyperkalemia. To this end, pilot safety studies with aldosterone-receptor antagonists in ESRD patients have begun. These studies imply that spironolactone can be safely used in carefully selected and closely monitored patients. Eplerenone has not been studied in ESRD in a therapeutic or safety capacity. Additional studies are needed with these compounds in the ESRD population before their use can be considered safe.