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Mineralocorticoid receptor antagonists for cardioprotection in chronic kidney disease: a step into the future

Journal of Human Hypertension volume 36, pages 695–704 (2022)Cite this article

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Abstract

Chronic kidney disease (CKD) and cardiovascular disease (CVD) share major risk factors and mechanistic pathways for progression. Furthermore, either decreased glomerular filtration rate or increased albuminuria are major risk factors for cardiovascular events. Evidence from previous renal outcome trials in patients with proteinuric CKD showed that angiotensin-converting-enzyme inhibitors (ACEIs) and angiotensin-II receptor blockers (ARBs) effectively slow CKD progression, establishing these agents as fundamental CKD pharmacologic treatments. However, in all these trials and subsequent meta-analyses, ACEIs and ARBs did not significantly reduce cardiovascular events or mortality, indicating a high residual risk for CVD progression in individuals with CKD. In contrast to the above, several outcome trials with old and novel mineralocorticoid receptor-antagonists (MRAs) clearly suggest that these agents, apart from nephroprotection, offer important cardioprotection in this population. This article is an overview of previous and recent evidence on the effects of MRAs on cardiovascular outcomes in patients with CKD attempting to highlight a pathway able to improve both cardiovascular and renal prognosis in this population.

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Fig. 1: Effects of finerenone on the key cardiovascular outcome (composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke or hospitalization for heart failure) in FIDELIO-DKD trial.
Fig. 2: Comparison of the effects of different renin-angiotensin-aldosterone system blockers on kidney and cardiovascular outcomes in patients with chronic kidney disease.

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Authors and Affiliations

  1. Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Maria-Eleni Alexandrou, Marieta P. Theodorakopoulou & Pantelis A. Sarafidis

  2. Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey

    Mehmet Kanbay

Authors
  1. Maria-Eleni Alexandrou
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  2. Marieta P. Theodorakopoulou
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  3. Mehmet Kanbay
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  4. Pantelis A. Sarafidis
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Contributions

All authors contributed to this study, which was conceived by PS and MK, and drafted by all authors (MA, MT, MK, and PS).

Corresponding author

Correspondence to Pantelis A. Sarafidis.

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Competing interests

PS is an advisor/speaker to Amgen, Astra Zeneca, Bayer, Boehringer Ingelheim, Elpen Pharmaceuticals, Genesis Pharma, Menarini, Innovis Pharma, Sanofi, Winmedica and has received research support for an Investigator-Initiated Study from Astra Zeneca. MA, MPT, and MK have no competing interests in relation to the work described.

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Alexandrou, ME., Theodorakopoulou, M.P., Kanbay, M. et al. Mineralocorticoid receptor antagonists for cardioprotection in chronic kidney disease: a step into the future. J Hum Hypertens 36, 695–704 (2022). https://doi.org/10.1038/s41371-021-00641-1

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  • DOI: https://doi.org/10.1038/s41371-021-00641-1

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