Mineralocorticoid Receptor Antagonist Use in Heart Failure With Reduced Ejection Fraction and End-Stage Renal Disease Patients on Dialysis

Abstract

Mineralocorticoid receptor antagonists (MRAs) are known to have a proven mortality benefit in heart failure with reduced ejection fraction (HFrEF) without kidney disease. As patients with end-stage renal disease (ESRD) requiring either peritoneal dialysis or hemodialysis were excluded in clinical trials of HFrEF, the data are scant on the appropriate use of MRAs in this population. The unknown efficacy, along with concerns of adverse effects such as hyperkalemia, has limited the willingness of clinicians to consider using MRAs in these patients. However, it is unclear whether the risk of hyperkalemia is present if a patient is oliguric or anuric. Current guidelines recommend against the use of MRAs in patients with chronic kidney disease, but do not address the use of MRAs in patients requiring dialysis. This article will review the epidemiology of heart failure in ESRD, the pathophysiological derangements of the renin–angiotensin–aldosterone system in patients with kidney disease, and the results from case series and trials of the use of MRAs in ESRD with HFrEF. Although limited to several small trials using MRAs in peritoneal and hemodialysis patients with or without HFrEF, the current literature appears to show the potential for clinical benefits with little risk.

Effect of Severity and Etiology of Chronic Kidney Disease in Patients With Heart Failure With Mildly Reduced Ejection Fraction

“…Our findings reveal that patients with more advanced stages of CKD (Stages 4 and 5) exhibit substantially higher mortality rates and more frequent hospitalizations compared to those in the early stages of CKD (Stages 1 and 2) (12). Specifically, the mortality rate was highest in CKD Stage 5 patients at 40%, compared to only 5.6% in CKD Stage 1 patients.…”

The recent advance and prospect of natural source compounds for the treatment of heart failure

“…MRAs can significantly inhibit collagen synthesis and alleviate myocardial fibrosis, which is significantly better than that of angiotensin receptor antagonists ACEIs and ARBs [ 81 ]. In addition, MRAs can regulate the balance of K + and Mg 2+ in myocardium and improve the diastolic and systolic functions to improve myocardial remodeling without affecting the repair of myocardial tissue and scar formation [ 82 ]. Therefore, MRAs can help ACEIs and ARBs to control the level of aldosterone, reduce myocardial and vascular fibrosis, improve ventricular remodeling and reduce the mortality and morbidity of patients with HF to become an important medicine for the treatment of HF.…”

Hyperkalemia in heart failure: current treatment and new therapeutic perspectives

“…Other mechanisms responsible for the increase in serum K + are reduced sodium excretion from the distal nephron, aldosterone deficiency, and collector tubule malfunction. Moreover, patients with HF often have many comorbidities, such as diabetes or renal failure, which reduce the ability to eliminate K + , resulting in increased hematic levels (Bhinder et al, 2020;Wetmore et al, 2019). Diabetes also acts through hyperglycemia, K + shift from intra-to extracellular compartment, hyporeninemia, and hypoaldosteronism.…”