Activation of the mineralocorticoid receptor (MR) has long been considered a risk factor for cardiovascular diseases. It has been reported that the novel MR blocker esaxerenone shows high potency and selectivity for MR in vitro as well as great antihypertensive and renoprotective effects in salt-sensitive hypertensive rats. Here, we determined the cocrystal structure of the MR ligand-binding domain (MR-LBD) with esaxerenone and found that esaxerenone binds to MR-LBD in a unique manner with large side-chain rearrangements, distinct from those of previously published MR antagonists. This structure also displays an antagonist form that has not been observed for MR previously. Such a unique binding mode of esaxerenone provides great insight into the novelty, potency, and selectivity of this novel antihypertensive drug.The mineralocorticoid receptor (MR) is a steroidal hormone-activated nuclear receptor that has received increasing attention as a driver of cardiovascular and renal injury. Substantial clinical evidence has been accumulated showing that the blockade of MR is an important treatment option for not only hypertension [1,2], but also heart failure [3-5] and chronic kidney diseases including diabetic nephropathy [6][7][8]. Although two MR antagonists with steroidal structures, spironolactone and eplerenone, are now clinically available, their clinical use has not been widely accepted because of safety and efficacy concerns. Spironolactone has poor selectivity over progesterone receptor (PR) and androgen receptor (AR), which causes side effects such as painful gynecomastia, menstrual irregularities, and impotence. Eplerenone has better selectivity but in compromise it has relatively low potency against MR and is contraindicated in patients with renal impairment due to the risk of hyperkalemia.Within the nuclear receptor superfamily, MR, PR, AR, and glucocorticoid receptor (GR) belong to the estrogen receptor-like subfamily, 3-ketosteroid receptor group (NR3C) [9]. These nuclear receptors share high sequence homology, and it has thus long been a Abbreviations AR, androgen receptor; GR, glucocorticoid receptor; MR, mineralocorticoid receptor; MR-LBD, MR ligand-binding domain; PR, progesterone receptor; SBDD, structure-based drug design.