What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?

Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.

There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...

There is some extra-renal aldosterone-dependent K secretion, especially in the gut, that helps K balance in pts with ESRD. This could be blocked by spironolactone. I would not hesitate using the drug if indicated, (resistant HTN or CHF) but I would initially keep a closer eye on the K. If it increas...

I try to use Spironolactone in ESKD patients with HFrEF patients.

The main side effect of spironolactone in patients with reduced renal function is hyperkalemia. This is not an issue in eGFR, because HyperK can be managed with HD. Therefore, I routinely use spironolactone in patients with HFrEF and ESRD.

We use ACE and ARBs in HFrEF with ESRD (and thus we imply t...

Use it very carefully. Personally, I would feel more comfortable with a heart failure specialist following these patients.

A recent study reported patients with renal failure randomized to spironolactone vs placebo. The patients in the spironolactone group derived significant benefit despite worseni...