Table 2.

Suggestions for minimizing and managing serious adverse events in CKD patients treated with MRBs

  1. Unless there is a compelling indication, avoid using MRBs in patients with eGFR <60 ml/min/1.73 m2.

  2. Avoid starting MRB therapy in any patient with baseline serum K+ in excess of 5.0 mEq/L.

  3. MRBs can be used as adjuncts to ACE inhibitors or ARBs in CKD patients with overt proteinuria (>300 mg/d) in whom maximal doses of ACE inhibitors or ARBs have not achieved the target for proteinuria reduction.

  4. MRBs should be started at low doses. Serum K+ should be checked 1 wk after starting or changing the MRB dose, and regularly thereafter.

  5. Dietary prudence with respect to K+ intake and regular bowel habits will help minimize elevations of serum K+. Avoid oral K+ supplements and salt substitutes.

  6. Be cautious using MRBs with more than 1 other inhibitor of the RAAS, with K+-sparing diuretics or with any other agent that suppresses renin secretion or activation (calcineurin inhibitors, non-steroidal anti-inflammatory agents, β-blockers, aliskiren, Vitamin D receptor agonists).

  7. Concomitant use of thiazides or furosemide may help control serum K+ in CKD patients with serum K+ > 4.5 mEq/L.

  8. If serum K+ rises above 5.0 mEq/L, decrease the dose of MRB or ACEI or ARB, modify the dietary K+ intake and check for constipation.

  9. If serum K+ is >5.5 mEq/L, stop the administration of MRBs, ACEIs, and ARBs, and modify dietary K+ intake. Check 24-h urine for K+ and Na+ excretion to confirm dietary patterns and interventions.

  • ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blockers; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; MRBs, mineralocorticoid receptor blockers; RAAS, renin-angiotensin-aldosterone system.