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Brand names: Aldactone • Drug class: Mineralocorticoid receptor antagonist (potassium-sparing diuretic)
Spironolactone helps heart failure and resistant hypertension — and its biggest kidney-related risk is hyperkalemia. In CKD, it's used carefully with potassium monitoring; the modern alternative finerenone offers kidney protection with a lower potassium risk.
Spironolactone blocks aldosterone, reducing potassium excretion — in CKD, where potassium handling is already impaired, this raises hyperkalemia risk. It also lowers blood pressure (protective in CKD) and reduces proteinuria in some settings. Guidelines allow it in heart failure with CKD if potassium <5.0 mEq/L, with monitoring; it's avoided when eGFR is very low or potassium is high.
RALES/EMPHASIS-HF: spironolactone saves lives in heart failure; hyperkalemia the main risk
NEJM 1999 / NEJM 2011, 1999/2011
Finerenone provides MR antagonism with less hyperkalemia in diabetic CKD
FIDELIO-DKD (NEJM 2020), 2020
Heart failure: 12.5-25 mg daily, potassium checked at 1 week and 1 month. eGFR <30 or potassium ≥5.0: generally avoid or use extreme caution with nephrology input. Combine with ACEi/ARB: monitor potassium and creatinine closely (triple whammy risk if NSAIDs added).
Check your kidney functionThis page is educational. Medication decisions — especially dosing changes — must be made by your prescribing clinician.
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