Elsevier

American Heart Journal

Volume 148, Issue 6, December 2004, Pages 971-978
American Heart Journal

Clinical investigations: Congestive heart failure
Spironolactone-induced renal insufficiency and hyperkalemia in patients with heart failure

https://doi.org/10.1016/j.ahj.2004.10.005Get rights and content

Abstract

Background

A previous randomized controlled trial evaluating the use of spironolactone in heart failure patients reported a low risk of hyperkalemia (2%) and renal insufficiency (0%). Because treatments for heart failure have changed since the benefits of spironolactone were reported, the prevalence of these complications may differ in current clinical practice. We therefore sought to determine the prevalence and clinical associations of hyperkalemia and renal insufficiency in heart failure patients treated with spironolactone.

Methods

We performed a case control study of heart failure patients treated with spironolactone in our clinical practice. Cases were patients who developed hyperkalemia (K+ >5.0 mEq/L) or renal insufficiency (Cr ≥2.5 mg/dL), and they were compared to 2 randomly selected controls per case. Clinical characteristics, medications, and serum chemistries at baseline and follow-up time periods were compared.

Results

Sixty-seven of 926 patients (7.2%) required discontinuation of spironolactone due to hyperkalemia (n = 33) or renal failure (n = 34). Patients who developed hyperkalemia were older and more likely to have diabetes, had higher baseline serum potassium levels and lower baseline potassium supplement doses, and were more likely to be treated with β-blockers than controls (n = 134). Patients who developed renal insufficiency had lower baseline body weight and higher baseline serum creatinine, required higher doses of loop diuretics, and were more likely to be treated with thiazide diuretics than controls.

Conclusions

Spironolactone-induced hyperkalemia and renal insufficiency are more common in our clinical experience than reported previously. This difference is explained by patient comorbidities and more frequent use of β-blockers.

Section snippets

Patients

Patients were selected from a consecutive series of 926 heart failure patients prescribed spironolactone by the University of Michigan Heart Failure Management Program between September, 1998 and January, 2002. All patients in the study had a documented left ventricular ejection fraction <35% in the medical record. Prescription of spironolactone was left to the discretion of the primary attending cardiologist at the University of Michigan.

Study design

A case control design was used to compare

Results

Of the 926 patients treated with spironolactone in our program, 67 patients (7.2 %) required discontinuation of the medication due to hyperkalemia (Group 1) or renal failure (Group 2). Of these 67 patients (cases), 33 of 67 patients (49%) required discontinuation of the medication due to hyperkalemia and 34 of 67 patients (51%) required discontinuation due to renal failure. Eleven of the 33 patients in Group 1 (33%) and 4 of the 34 patients in Group 2 (12%) had serum potassium level ≥6.0 mEq/L

Discussion

In our cohort of patients with heart failure treated with spironolactone, 7.2% patients required discontinuation of the medication due to clinically determined hyperkalemia (3.6%) or renal insufficiency (3.7%). The rate of serious hyperkalemia (K+ ≥6.0 mEq/L) with spironolactone experienced in our patient population (1.6%) is similar to the 2% rate reported by the RALES investigators.2 We observed that 0.3% of our population experienced a rise in creatinine >4.0 mg/dL, a side effect not

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