Mineral receptor antagonists are not beneficial for patients undergoing dialysis

According to a meta-analysis, mineral receptor antagonists (MRAs), specifically spironolactone and eplerenone, do not lead to cardiac death or reduce all-cause mortality but increase rates of hyperkalaemia and gynecomastia/breast pain in patients undergoing dialysis.

The meta-analysis presented by Dr Lonnie Pyne (McMaster University, Canada) included a total of 19 randomised-controlled trials (9 not part of previous meta-analyses), including the large ACHIEVE (NCT03020303) and ALCHEMIST (NCT01848639) trials [1]. Trial participants were adults with kidney failure receiving dialysis, who were receiving MRAs and either a placebo or the best standard-of-care as a comparator.

Due to considerable heterogeneity among the trials, the analysis focused on trials with low risk of bias. Among these trials, MRA versus comparator did not significantly improve cardiovascular mortality (OR 0.98; 95% CI 0.80–1.20), all-cause mortality (OR 0.97; 95% CI 0.84–1.12), or hospitalisation due to heart failure (OR 0.70; 95% CI 0.30–1.65), nor did it lead to increased hypotension (OR 1.04; 95% CI 0.61–1.78). However, MRA use led to increased hyperkalaemia events (defined as serum potassium ≥6.5 mmol/L; OR 1.50; 95% CI 1.11–2.03), and the composite of gynecomastia and/or breast pain (OR 3.66; 95% CI 1.82–7.36). It should be noted that most trials included were of spironolactone, and only 1 assessed eplerenone.

“MRAs do not have evidence of benefit and they do carry potential harms, namely hyperkalaemia, gynecomastia, and breast pain, for patients with kidney failure requiring dialysis,” concluded Dr Pyne. “The risk of cardiovascular death remains high in this patient population and effective therapies remain urgently needed. Our analysis helps to illustrate the importance of high-quality, adequately powered trials to provide clear evidence, particularly when contrasted by the systematic reviews and meta-analyses on this topic before the inclusion of the recently completed large randomised trials.”

1. Pyne L, et al. Mineralocorticoid receptor antagonists in patients with kidney failure receiving dialysis: an updated systematic review and meta-analysis. 62nd ERA Congress, 4–7 June 2025, Vienna, Austria.

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Posted on 22 August 202522 August 2025