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.

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 worsen...