Steroidal mineralocorticoid receptor antagonists show little mortality benefit in patients receiving dialysis

1. Cardiovascular mortality and heart failure-related hospitalization were slightly less in the steroidal MRA group, though there was no statistical significance.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Mineralocorticoid receptor antagonists (MRAs) are known to reduce cardiovascular events in patients with heart failure and mild-to-moderate kidney disease. Yet, their role in patients with kidney failure on dialysis remains unclear. This randomized controlled trial aimed to assess the efficacy and safety of MRAs in adults receiving maintenance dialysis. The primary outcome of this study was cardiovascular mortality, while key secondary outcome was heart failure hospitalization. According to study results, steroidal MRAs had little to no effect on cardiovascular mortality in dialysis patients. Although this study was well done, it was limited by insufficient data in patient subgroups and the lack of information on non-steroidal MRAs.

Click to read the study in The Lancet

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In-depth [systematic review and meta-analysis]: 19 randomized controlled trials of steroidal MRAs were included from database inception to Mar 18, 2025. Included were patients ≥ 18 years receiving maintenance dialysis who were enrolled in trials comparing a mineralocorticoid receptor antagonist with placebo or standard of care. Altogether, 4675 patients were included in the final analysis. The primary outcome of cardiovascular mortality showed no significant difference between treatment and control groups (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.80–1.20). The secondary outcome of heart failure hospitalization also showed no clear benefit (OR 0.70, 95% CI 0.30-1.65). Overall, findings from this study suggest that steroidal MRAs provide little cardiovascular benefit for patients requiring dialysis.

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