Mineralocorticoid receptor antagonists in chronic kidney disease - pros and cons

Aldosterone takes part in the regulation of body fluid volume, blood pressure and kalemia. In a number of pathological conditions, including chronic kidney disease (CKD), secondary hyperaldosteronism occurs, leading to development of edema, hypervolemia and hypertension. Aldosterone has also a proinflammatory action, leading to heart and blood vessels damage, and is an independent risk factor of death. Some of the research conducted to confirm the expected benefits of angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) therapy in CKD patients did not yield positive results, probably due to "aldosterone escape". Mineralocorticoid receptor antagonists (MRA) are being introduced also in the treatment of CKD patients, although the risk of developing hyperkalemia exists. A number of papers suggest a positive influence of MRA on slowing down the progression of renal failure, reduction of cardiovascular risk, and decreasing mortality, with relative safety of treatment, however the data are based on small and heterogenous groups of patients, therefore conclusive information is expected from large trials which are currently being conducted (BARACK D, ALCHEMIST).