Mineralocorticoid Receptor Antagonists in Advanced CKD: A Safety and Efficacy Systematic Review

Abstract

Introduction: Mineralocorticoid receptor antagonists (MRAs) reduce albuminuria and cardiovascular events, but hyperkalemia concerns limit use in advanced CKD (eGFR <30 mL/min/1.73m²). Emerging non-steroidal MRAs (finerenone) may offer better safety profile. This review compares steroidal vs. non-steroidal MRAs in CKD stage 4–5.
Methods: PRISMA-compliant search of Scopus and Web of Science (2018–2024). Inclusion: RCTs or prospective cohorts with ≥50 participants, eGFR <30, on MRA ≥6 months. Outcomes: change in UACR, serum potassium >5.5 mEq/L, and hospitalization for hyperkalemia.
Results: Ten studies (n=3,201) included. Finerenone reduced UACR by 33% (95% CI 28–38) vs. spironolactone 21% (95% CI 15–27). Hyperkalemia rates: finerenone 8.2% vs. spironolactone 17.6% (p=0.002). No significant difference in eGFR decline slope (-2.1 vs -2.4 mL/min/year, p=0.31). All-cause mortality lower with finerenone (HR 0.79, 95% CI 0.65–0.96).
Discussion: Non-steroidal MRAs achieve superior anti-albuminuric effect with significantly less hyperkalemia due to selective receptor binding and less renal tubular accumulation. However, most studies excluded patients with baseline potassium >5.0 mEq/L.
Conclusions: Finerenone appears safer than spironolactone in advanced CKD, but regular potassium monitoring remains essential.