Key result
Selective aldosterone synthase inhibitors significantly reduced systolic blood pressure by 7.9 mmHg (95% CI -10.0 to -5.9) compared to placebo in patients with CKD, but increased hyperkalemia risk.
Why the study?
Hypertension is frequently uncontrolled in CKD, and evidence regarding the blood pressure-lowering effects of selective aldosterone synthase inhibitors in patients with CKD remains limited.
Do selective aldosterone synthase inhibitors reduce blood pressure in patients with chronic kidney disease?
Meta-Analysis (n=1,148)
Do selective aldosterone synthase inhibitors reduce blood pressure in patients with chronic kidney disease?
Mean Difference: -7.9 (95% CI -10–-5.9)
Selective aldosterone synthase inhibitors significantly reduce systolic and diastolic blood pressure as well as albuminuria in patients with CKD, though they are associated with an increased risk of hyperkalemia.
Supports ASIs for SBP reduction in CKD with hyperkalemia monitoring; extends resistant hypertension efficacy data to this population.
Objective: Hypertension is highly prevalent in CKD and frequently remains uncontrolled despite high treatment rates. Aldosterone synthase inhibitors (ASIs) have demonstrated significant blood pressure (BP) lowering efficacy in patients with uncontrolled or resistant hypertension; however, evidence regarding their effects in patients with CKD remains limited. This is the first systematic review and meta-analysis exploring the efficacy and safety of selective ASIs for BP reduction in CKD. Design and method: A systematic search was performed in major electronic databases, clinical trial registries and grey literature up to December 2025. We included randomized controlled trials (RCTs) assessing the effect of selective ASIs (agents with selectivity for CYP11B2) compared with placebo on BP levels in patients with prevalent CKD at baseline. Secondary outcomes included albuminuria levels (UACR), eGFR change and hyperkalemia incidence. Both random-effects and fixed-effects meta-analyses were conducted, based on heterogeneity. Results: Five RCTs involving 1,148 patients were included in the analysis for the primary outcome; 2 used baxdrostat, 2 lorundrostat and 1 study used vicadrostat. Treatment with ASIs was associated with a significant placebo-adjusted reduction in SBP of-7.9 mmHg (95%CI -10.0 to -5.9, I2=0%) (Figure 1) and DBP of -3.1 mmHg (95% CI -5.9 to -0.2, I2=62%). Treatment with ASIs also reduced UACR by -31.7% (95%CI -54.5 to -8.9, I2=91%). The pooled placebo-adjusted eGFR change was -2.05 mL/min/1.73 m2 (95% CI -3.15 to -0.95, I2=0%). The risk of hyperkalemia was higher with ASIs compared to placebo, but with high heterogeneity (risk ratio, 4.04 [95% CI 0.94 to 17.35], I2=76%).Conclusions: Selective ASIs significantly reduce SBP/DBP and albuminuria levels in patients with CKD. Treatment was associated with an increased risk of hyperkalemia, highlighting the importance of close monitoring. These findings suggest ASIs as a potential treatment option for BP control in patients with CKD, pending confirmation in the future, larger RCTs.
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Theodorakopoulou et al. (2026) conducted a meta-analysis in Chronic Kidney Disease (CKD) (n=1,148). Selective aldosterone synthase inhibitors (ASIs) vs. Placebo was evaluated on Placebo-adjusted reduction in systolic blood pressure (SBP) (MD -7.9 mmHg, 95% CI -10.0 to -5.9). Selective aldosterone synthase inhibitors significantly reduced systolic blood pressure by 7.9 mmHg (95% CI -10.0 to -5.9) compared to placebo in patients with CKD, but increased hyperkalemia risk.
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