FF 84 ACHIEVE: Spironolactone flops in dialysis

The Filtrate Joel Topf‍ ‍@kidneyboy.bsky.social‬ Swapnil [email protected] AC @medpeedskidneys.bsky.social Special Guest Mike Walsh Associate Professor in the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University as well as a Scientist at the Population Health Research Institute and a nephrologist at St. Joseph’s Healthcare Hamilton where he is the Chair of the Clinical Nephrology Research Group. Editing and Show Notes by Sophia Ambruso The Kidney Connection written and performed by Tim Yau Show Notes ALCHEMIST (NephJC Shorts, Rossignol et al Lancet 2025) AC is in her 83rd year of med-peds fellowship. Joel’s monologue brings us all down. Prophylactic ICD therapy doesn’t improve sudden cardiac death or all-cause mortality in HD patients in the ICD2 trial (Jukema JW et al. Circulation 2019) Initiation with statins do not impact MACE endpoints or atherosclerotic events (4D AURORA trial Fellstrom BC et al. NEJM 2009 & SHARP trial Baigent C et al. Lancet 2011) Mike tries to liven up the mood by mentioning positive outcomes with iron therapy in heart failure with the PIVOTAL trial (Macdougall IC et al. NEJM 2018) TOPHAT trial revealed treatment with spironolactone in HFpEF did not affect MACE outcomes. (Pitt B et al. NEJM 2014) NephTrials ‘Run-in periods in clinical trials: What can we ACHIEVE?’ SPIN D trial - spironolactone dose finding trial in ESRD (Charytan DM et al. Kidney Int 2018) Mike shares the human experience of the trial after being instructed to end the trial prematurely and being told they have “answered their question” Study in Japan - spironolactone predominantly benefits male over females (cannot find this) Male vs female benefit not observed in ACHIEVE despite Mike’s initial hypothesis Swap compares and contrasts ACHIEVE, ALCHEMIST & Meta-analysis (Pyne L et al. Lancet 2025) Mike discusses how nonadherence to spironolactone impacted the intention to treat outcomes in the trial. What is a high risk of bias for dummies? Mike, Swap & Joel ponder future nsMRA or ASI trials hemodialysis? Tubular secretions Swap is probably stalking Martha Wells by now, has moved on from Witch King, now onto Queen Demon on Good Reads AC is adding to her brood, 2 dogs (Snickers & Harper), 1 child Dungeon Crawler Call - a science fantasy book series by Matt Dinniman (on goodreads), which he lovingly referred to as complete nerd trash. Joel is binging on the series Task on HBO max, featuring Mark Ruffalo as FBI agent. NephJC is having its annual fundraiser (get your tickets here) at ASN. Providing a party shuttle that is leaving every 30 minutes from the conference center. As always, it will feature a live podcast recording covering the ASN late breaking, high impact clinical trials. Swap describes the high impact model at ASN this year - go big or go home.