Mineralocorticoid receptor antagonists (MRAs) appear to lower mortality risks in patients receiving dialysis without substantially increasing the risk for hyperkalemia, according to investigators.

Chih-Chin Kao, MD, of Taipei Medical University Hospital in Taipei, Taiwan, and colleagues conducted a systematic review and meta-analysis of MRA trials published up to 2020. The review included 13 trials of spironolactone and 1 trial of eplerenone and involved a total of 1309 patients on dialysis for kidney failure (mean age 53-70 years). MRA use was significantly associated with a 59% lower risk for cardiovascular mortality and a 56% lower risk for all-cause mortality, the investigators reported in the Clinical Journal of the American Society of Nephrology. Taking MRAs did not significantly decrease the risk for nonfatal cardiovascular events, stroke, and blood pressure. The researchers were unable to assess cardiac function, left ventricular ejection fraction, and left ventricular mass index.

In a meta-analysis of 7 of the trials, hyperkalemia risk did not differ significantly between the MRA and control group. An examination of pre- and post-treatment serum potassium levels in all 13 trials, however, yielded mixed results. Hyperkalemia was defined as a serum potassium level of more than 5.5 mmol/L in 3 trials, 6.0 mmol/L in 4 trials, and 6.5 mmol/L in 3 trials. These findings, which reflect data from some recent trials, contradict findings from a 2016 meta-analysis that found a significantly higher risk for hyperkalemia in MRA-treated patients.

Continue Reading

In a discussion of study limitations, the investigators noted that most of the trials were not designed to study hard clinical endpoints. In addition, MRA doses and length of follow-up differed.

“In summary, our meta-analysis suggested that MRAs might improve clinical outcomes in patients with kidney failure treated with dialysis without significant increase in the risk of hyperkalemia,” Dr Kao’s team concluded. “However, it is still prudent to monitor patients’ serum potassium levels more closely while taking these medications.”

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Chen K-T, Kang Y-N, Lin Y-C, et al. Efficacy and safety of mineralocorticoid receptor antagonists in kidney failure patients treated with dialysis: a systematic review and meta-analysis. Clin J Am Soc Nephrol 16(6):916-925. doi:10.2215/CJN.15841020

Quach K, Lvtvyn L, Baigent C, et al. The safety and efficacy of mineralocorticoid receptor antagonists in patients who require dialysis: A systematic review and meta-analysis. Am J Kidney Dis. 2016;68:591–598.