Aldosterone synthase inhibition for treatment of people with chronic kidney disease

Aldosterone contributes to the progression of chronic kidney disease (CKD) not only through its effects on blood pressure (BP) but also by promoting inflammation and fibrosis in the kidney and cardiovascular system. Despite contemporary treatment with renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 (SGLT2) inhibitors, residual risk persists for adverse kidney and cardiovascular outcomes. Aldosterone synthase inhibition (ASI) has emerged as a potent strategy to directly suppress aldosterone production. Several selective inhibitors, including baxdrostat, lorundrostat, and vicadrostat, have been shown to lower aldosterone levels without affecting cortisol synthesis in a clinically meaningful manner. Clinical studies in hypertension consistently show a decrease in systolic BP with these agents. In a CKD population, vicadrostat dose-dependently reduced the urinary albumin-to-creatinine ratio with additional BP lowering, and possibly greater albuminuria reduction when combined with empagliflozin. Similar findings have been observed with lorundrostat and baxdrostat in patients with CKD and uncontrolled hypertension. Median increases in serum potassium of ∼0.3 mmol/l that have been observed with ASI were generally manageable in clinical trial populations. Emerging evidence from clinical trials and meta-analyses suggests that concomitant SGLT2 inhibitor therapy may mitigate the risk of clinically significant hyperkalaemia, also supporting the use of combination therapy. Overall, ASI provide a potentially beneficial approach to reduce residual risks of CKD. Several phase 3 trials testing vicadrostat or baxdrostat across different populations with CKD, hypertension, or cardiovascular disease will determine whether favourable effects on albuminuria translate into improved kidney and cardiovascular outcomes.