Mineralocorticoid Receptor Antagonist use in Renal Dialysis: Will Evidence from Prospective Randomized Trials Confirm the Results from ‘Real-World’ Evidence?

In patients with end-stage renal disease (ESRD) on chronic renal dialysis the cardiovascular (CV) mortality rate is 10 to 20 times higher than in the general population and among adults younger than 45 years of age the mortality rate is approximately 100 times higher than that in the general population.Hence, treatments to improve survival, more specifically CV outcomes, in this population are urgently needed. 1,2ctivation of mineralocorticoid receptors (MR) in patients with chronic kidney disease (CKD) leads to adverse outcomes, especially hospitalization for heart failure (HF), ventricular arrhythmias, sudden cardiac death as well as progression of CKD to ESRD 2,3 through several mechanisms, including inflammation, oxidative stress, endothelial dysfunction, vascular fibrosis, stiffening and calcification, 3-5 all of which are relevant in patients undergoing renal dialysis. 2MR antagonists (MRAs) are currently approved and/or are recommended in European and international guidelines in patients with resistant hypertension, diabetic nephropathy and in HF with a reduced ejection fraction (HFrEF), where they are one of the 'four pillars' along with angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), sacubitril/valsartan, beta-blockers, and sodium-glucose cotransporter 2 inhibitors.MRAs are therefore prime candidates to be assessed in prospective randomized clinical trials in patients undergoing renal dialysis.However, in view of the risk of The opinions expressed in this article are not necessarily those