Mineralocorticoid receptor antagonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease.
Ortiz, Alberto Ferro, Charles J Balafa, Olga Burnier, Michel Ekart, Robert Halimi, Jean-Michel Kreutz, Reinhold Mark, Patrick B Persu, Alexandre Rossignol, Patrick
Ortiz, Alberto
Ferro, Charles J
Balafa, Olga
Burnier, Michel
Ekart, Robert
Halimi, Jean-Michel
Kreutz, Reinhold
Mark, Patrick B
Persu, Alexandre
Rossignol, Patrick
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2023-01-23
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Abstract
Diabetic kidney disease (DKD) develops in ∼40% of patients with diabetes and is the most common cause of chronic kidney disease (CKD) worldwide. Patients with CKD, especially those with diabetes mellitus, are at high risk of both developing kidney failure and cardiovascular (CV) death. The use of renin-angiotensin system (RAS) blockers to reduce the incidence of kidney failure in patients with DKD dates back to studies that are now ≥20 years old. During the last few years, sodium-glucose co-transporter-2 inhibitors (SGLT2is) have shown beneficial renal effects in randomized trials. However, even in response to combined treatment with RAS blockers and SGLT2is, the renal residual risk remains high with kidney failure only deferred, but not avoided. The risk of CV death also remains high even with optimal current treatment. Steroidal mineralocorticoid receptor antagonists (MRAs) reduce albuminuria and surrogate markers of CV disease in patients already on optimal therapy. However, their use has been curtailed by the significant risk of hyperkalaemia. In the FInerenone in reducing kiDnEy faiLure and dIsease prOgression in DKD (FIDELIO-DKD) study comparing the actions of the non-steroidal MRA finerenone with placebo, finerenone reduced the progression of DKD and the incidence of CV events, with a relatively safe adverse event profile. This document presents in detail the available evidence on the cardioprotective and nephroprotective effects of MRAs, analyses the potential mechanisms involved and discusses their potential future place in the treatment of patients with diabetic CKD.
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Ortiz A, Ferro CJ, Balafa O, Burnier M, Ekart R, Halimi JM, Kreutz R, Mark PB, Persu A, Rossignol P, Ruilope LM, Schmieder RE, Valdivielso JM, Del Vecchio L, Zoccali C, Mallamaci F, Sarafidis P; European Renal and Cardiovascular Medicine (EURECA-m) Working Group of the European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney Working Group of the European Society of Hypertension (ESH). Mineralocorticoid receptor antagonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease. Nephrol Dial Transplant. 2023 Jan 23;38(1):10-25. doi: 10.1093/ndt/gfab167
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Article