The Safety and Efficacy of Mineralocorticoid Receptor Antagonists in Patients Who Require Dialysis: A Systematic Review and Meta-analysis

Kevin Quach, Lyubov Lvtvyn, Colin Baigent, Joe Bueti, Amit X. Garg, Carmel Hawley, Richard Haynes, Braden Manns, Vlado Perkovic, Christian G. Rabbat, Ron Wald, Michael Walsh

Research output: Contribution to journalArticle

Abstract

Background Patients who require dialysis are at high risk for cardiovascular mortality, which may be improved by mineralocorticoid receptor antagonists (MRAs). Study Design Systematic review and meta-analysis of randomized controlled trials. Setting & Population Adults undergoing long-term hemodialysis or peritoneal dialysis with or without heart failure. Selection Criteria for Studies Randomized controlled trials evaluating an MRA in dialysis and reported at least one outcome of interest. Intervention Spironolactone (8 trials) or eplerenone (1 trial) compared to placebo (7 trials) or standard of care (2 trials). Outcomes Cardiovascular and all-cause mortality, hyperkalemia, serum potassium level, hypotension, change in blood pressure, and gynecomastia. Results We identified 9 trials including 829 patients. The overall quality of evidence was low due to methodologic limitations in most of the included trials. The relative risk (RR) for cardiovascular mortality was 0.34 (95% CI, 0.15-0.75) for MRA-treated compared with control patients. The RR for all-cause mortality was 0.40 (95% CI, 0.23-0.69). The RR for hyperkalemia for MRA treatment was 3.05 (95% CI, 1.21-7.70). Sensitivity analyses demonstrated wide variability in RRs for cardiovascular mortality, all-cause mortality, and hyperkalemia, suggesting further uncertainty in the confidence of the primary results. Limitations Trial quality and size insufficient to robustly and precisely identify a treatment effect. Conclusions Given the uncertainty of both the benefits and harms of MRAs in dialysis, large high-quality trials are required.

Original languageEnglish (US)
Pages (from-to)591-598
Number of pages8
JournalAmerican Journal of Kidney Diseases
Volume68
Issue number4
DOIs
Publication statusPublished - Oct 1 2016
Externally publishedYes

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Keywords

  • adverse events
  • aldosterone
  • all-cause mortality
  • blood pressure
  • cardiovascular death
  • end-stage renal disease (ESRD)
  • eplerenone
  • hemodialysis
  • hyperkalemia
  • meta-analysis
  • Mineralocorticoid receptor antagonist (MRA)
  • peritoneal dialysis
  • randomized controlled trials
  • spironolactone
  • systematic review

ASJC Scopus subject areas

  • Nephrology

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