Schepkens H, Vanholder R, Billiouw J M, Lameire N
Department of Internal Medicine, Renal Division, University Hospital, Gent, Belgium.
Am J Med. 2001 Apr 15;110(6):438-41. doi: 10.1016/s0002-9343(01)00642-8.
The beneficial effects of spironolactone are additive to those of ACE inhibitors among patients with heart failure and/or hypertension; however, it is essential to identify patients prone to develop serious hyperkalemia during combined treatment and to evaluate the associated morbidity and mortality.
We studied 25 patients treated with ACE inhibitors and spironolactone who were admitted to the emergency room with a serum potassium level > 6 mmol/L. Patients were followed up for at least one month after admission.
The mean age of the patients (11 males, 14 females) was 74 +/- 13 years. Five patients were diabetics. On admission, the serum potassium was 7.7 +/- 0.7 mmol/L and the serum creatinine was 3.8 +/- 1.8 mg/dL; these values were significantly higher than the most recent follow-up laboratory measurements (4.6 +/- 0.5 mmol/L and 1.9 +/- 1.2 mg/dL, respectively) obtained at 13 +/- 5 weeks before admission. The arterial pH on admission was 7.3 +/- 0.1 and the plasma bicarbonate was 18 +/- 5 mmol/L. The main causes for acute renal failure were dehydration (n = 12) and worsening heart failure (n = 9). The mean daily dose of spironolactone was 57 +/- 32 mg and 12 patients were concomitantly treated with other drugs that may cause hyperkalemia. Two patients died, and 2 patients were resuscitated but survived. Hemodialysis was necessary in 17 patients; 12 patients were admitted to the intensive care unit. The mean duration of hospitalization was 12 +/- 6 days. Two patients needed to be started on maintenance hemodialysis therapy.
A combination of ACE inhibitors and spironolactone should be considered with caution and monitored closely in patients with renal insufficiency, diabetes, older age, worsening heart failure, a risk for dehydration, and in combination with other medications that may cause hyperkalemia. A daily spironolactone dose of 25 mg should not be exceeded.
在心力衰竭和/或高血压患者中，螺内酯的有益作用与血管紧张素转换酶（ACE）抑制剂的作用具有相加性；然而，识别联合治疗期间易发生严重高钾血症的患者并评估相关的发病率和死亡率至关重要。
我们研究了25例接受ACE抑制剂和螺内酯治疗且因血清钾水平>6 mmol/L而入住急诊室的患者。患者入院后至少随访1个月。
患者（11例男性，14例女性）的平均年龄为74±13岁。5例患者为糖尿病患者。入院时，血清钾为7.7±0.7 mmol/L，血清肌酐为3.8±1.8 mg/dL；这些值显著高于入院前13±5周获得的最近一次随访实验室测量值（分别为4.6±0.5 mmol/L和1.9±1.2 mg/dL）。入院时动脉血pH值为7.3±0.1，血浆碳酸氢盐为18±5 mmol/L。急性肾衰竭的主要原因是脱水（n = 12）和心力衰竭恶化（n = 9）。螺内酯的平均日剂量为57±32 mg，12例患者同时接受了其他可能导致高钾血症的药物治疗。2例患者死亡，2例患者经复苏存活。17例患者需要进行血液透析；12例患者入住重症监护病房。平均住院时间为12±6天。2例患者需要开始维持性血液透析治疗。
对于肾功能不全、糖尿病、老年、心力衰竭恶化、有脱水风险以及联合使用其他可能导致高钾血症药物的患者，应谨慎考虑联合使用ACE抑制剂和螺内酯，并密切监测。螺内酯的日剂量不应超过25 mg。
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