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Mineralocorticoid Receptor Antagonists in Dialysis
Elias John Elenjickal1,2,3, Thomas A Mavrakanas4,5
1Department of Medicine, McGill University Health Center, Montreal, Québec, Canada.
American Journal of Nephrology
|April 15, 2026
Summary
Steroidal mineralocorticoid receptor antagonists (MRAs) do not offer cardiovascular benefits for dialysis patients. These drugs also increase risks of hyperkalemia and endocrine side effects, making them unsuitable for this population.
Area of Science:
- Nephrology
- Cardiology
- Pharmacology
Background:
- Aldosterone, via mineralocorticoid receptor (MR) activation, influences fluid balance and can promote adverse cardiovascular and renal effects.
- Steroidal MRAs are established treatments for heart failure and diabetic kidney disease but were excluded from major trials in dialysis patients.
- Previous studies on MRAs in dialysis have yielded inconsistent results, necessitating a comprehensive review.
Purpose of the Study:
- To review the biological rationale for MR blockade in dialysis patients.
- To summarize the evolving clinical evidence for MRA use in this population.
- To discuss future research directions for MR blockade in patients undergoing dialysis.
Main Methods:
- Review of pharmacokinetic data for steroidal MRAs (spironolactone, eplerenone) in dialysis.
- Analysis of early randomized trials and large multicenter trials (ALCHEMIST, ACHIEVE) evaluating MRAs in dialysis patients.
- Inclusion of a contemporary meta-analysis of MRA trials in dialysis.
Main Results:
- Steroidal MRAs are not dialyzable and require careful potassium monitoring.
- Large trials (ALCHEMIST, ACHIEVE) showed no cardiovascular benefit with spironolactone in dialysis patients.
- MRAs in dialysis were associated with increased rates of hyperkalemia and gynecomastia.
Conclusions:
- Steroidal MRAs do not improve cardiovascular outcomes or survival in patients on maintenance dialysis.
- The use of steroidal MRAs in dialysis patients is linked to a modest increase in hyperkalemia and endocrine adverse events.
- Current evidence does not support the use of steroidal MRAs for cardiovascular benefit in dialysis populations.
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