To evaluate the literature supporting the safe use of mineralocorticoid antagonists (MRAs) in patients with end-stage renal disease who are receiving hemodialysis.

A review of the literature was performed using MEDLINE (1950 through week 2 of February 2012) using the key words and MeSH terms mineralocorticoid antagonists, aldosterone antagonists, spironolactone, or eplerenone combined with dialysis, renal disease, or kidney disease.

Studies eligible for inclusion evaluated the impact of MRAs on serum potassium levels in patients with end-stage renal disease receiving hemodialysis. Data related to the patient populations and outcomes of interest were extracted from each publication.

Ten studies were included in this review (spironolactone, 9; eplerenone, 1) and reported on the impact of MRAs on potassium levels in this population. In aggregate, the studies, with spironolactone doses ranging from 25 mg 3 times/week after dialysis to 300 mg/day and eplerenone doses of 25 mg twice daily, have shown little increases in serum potassium, particularly with the lower doses. The overall incidence of severe hyperkalemia was low. The literature base is limited by significant methodologic weaknesses of the studies, including low patient numbers, short follow-up periods, and lack of a blinded control group.

The current literature suggests that MRAs may be used safely in patients with end-stage renal disease receiving hemodialysis, although additional large controlled trials are needed before definitive treatment recommendations can be made.