Steroidal mineralocorticoid receptor antagonist offers no CV mortality benefit in dialysis patients

Treatment with steroidal mineralocorticoid receptor antagonists does not appear to provide significant protection against cardiovascular mortality in patients undergoing dialysis, as shown in a systematic review and meta-analysis.

Researchers searched multiple online databases for randomized controlled trials wherein a mineralocorticoid receptor antagonist was compared with placebo or standard of care in adults receiving maintenance dialysis. Outcomes of interest included cardiovascular mortality, heart failure hospitalization, all-cause mortality, all-cause hospitalization, hyperkalaemia, gynaecomastia or breast pain, and hypotension.

The risk of bias was assessed using the Cochrane risk-of-bias tool, and empirical Bayes random-effects models were applied in the meta-analysis.

A total of 19 trials involving 4,675 participants met the eligibility criteria. Effect estimates varied across trials with low and high risk of bias.

Pooled data from four trials (n=3,562) with a low risk of bias revealed 264 cardiovascular deaths among 1,785 patients treated with a mineralocorticoid receptor antagonist compared with 276 among 1,777 patients who received the control treatment (odds ratio, 0.98, 95 percent confidence interval, 0.80–1.20; I²=0.0 percent). The difference translated to an absolute risk reduction of 1 fewer event per 1,000 patients per year with a mineralocorticoid receptor antagonist.

Mineralocorticoid receptor antagonists have been shown to prevent cardiovascular events in patients with heart failure and nonsevere chronic kidney disease. The present data suggest little to no benefit in the population of patients undergoing dialysis.

The researchers acknowledged the insufficiency of information regarding the effects of the drug in this subgroup of patients and the lack of evidence on nonsteroidal mineralocorticoid receptor antagonists. They called for more studies to investigate the likelihood of only smaller effects or effects limited to patients or events with pathophysiology that is driven by aldosterone.