Resistant Hypertension Spironolactone CKD — ESENeph MCQ

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ModerateHypertensionResistant Hypertension Spironolactone CKDESENeph

A 58-year-old man with CKD G3b has resistant hypertension despite Ramipril 10 mg, Amlodipine 10 mg, and Indapamide 2.5 mg. His BP is 158/94. NICE NG136 step 4 for resistant hypertension recommends adding low-dose Spironolactone if potassium is ≤4.5 mmol/L. His potassium is 4.2 mmol/L. What monitoring is essential after starting Spironolactone in CKD?

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Correct answer: D — Check potassium and creatinine promptly

Spironolactone in CKD significantly increases hyperkalaemia risk, especially when combined with RASi. NICE NG136 recommends potassium and renal function monitoring within 1 week of starting, then 4-weekly until stable. If potassium rises above 5.0 mmol/L, dose reduction or cessation should be considered. The PATHWAY-2 trial showed Spironolactone was the most effective add-on agent for resistant hypertension, but CKD patients need careful monitoring. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: NICE NG136 2019 – Hypertension; PATHWAY-2 Trial – Lancet 2015: https://www.nice.org.uk/guidance/ng136/chapter/recommendations