The Safety and Efficacy of Mineralocorticoid Receptor Antagonists in Patients Who Require Dialysis: A Systematic Review and Meta-analysis

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• 作者：Kevin Quach ; MSc¹ ; Lyubov Lvtvyn ; MSc¹ ; Colin Baigent ; FRCP² ; Joe Bueti ; MD³ ; Amit X. Garg ; MD ; PhD⁴ ; ⁵ ; Carmel Hawley ; MBBS ; MMedSci⁶ ; ⁷ ; Richard Haynes ; DM² ; Braden Manns ; MD ; MSc⁸ ; ⁹ ; Vlado Perkovic ; MD ; PhD¹⁰ ; Christian G. Rabbat ; MD ; MSc¹¹ ; Ron Wald ; MDCM ; MPH¹² ; Michael Walsh ; MD ; PhD¹ ; ¹¹ ; ¹³ ; ^{lastwalsh1975@gmail.com" class="auth_mail" title="E-mail the corresponding author}
• 关键词：Mineralocorticoid receptor antagonist (MRA) ; spironolactone ; eplerenone ; hemodialysis ; peritoneal dialysis ; cardiovascular death ; all-cause mortality ; hyperkalemia ; blood pressure ; adverse events ; randomized controlled trials ; aldosterone ; end-stage renal disease (ESRD) ; systematic review ; meta-analysis
• 刊名：American Journal of Kidney Diseases
• 出版年：2016
• 出版时间：October 2016
• 年：2016
• 卷：68
• 期：4
• 页码：591-598
• 全文大小：528 K

文摘

Patients who require dialysis are at high risk for cardiovascular mortality, which may be improved by mineralocorticoid receptor antagonists (MRAs).

Study Design

Systematic review and meta-analysis of randomized controlled trials.

Setting & Population

Adults undergoing long-term hemodialysis or peritoneal dialysis with or without heart failure.

Selection Criteria for Studies

Randomized controlled trials evaluating an MRA in dialysis and reported at least one outcome of interest.

Intervention

Spironolactone (8 trials) or eplerenone (1 trial) compared to placebo (7 trials) or standard of care (2 trials).

Outcomes

Cardiovascular and all-cause mortality, hyperkalemia, serum potassium level, hypotension, change in blood pressure, and gynecomastia.

Results

We identified 9 trials including 829 patients. The overall quality of evidence was low due to methodologic limitations in most of the included trials. The relative risk (RR) for cardiovascular mortality was 0.34 (95% CI, 0.15-0.75) for MRA-treated compared with control patients. The RR for all-cause mortality was 0.40 (95% CI, 0.23-0.69). The RR for hyperkalemia for MRA treatment was 3.05 (95% CI, 1.21-7.70). Sensitivity analyses demonstrated wide variability in RRs for cardiovascular mortality, all-cause mortality, and hyperkalemia, suggesting further uncertainty in the confidence of the primary results.

Limitations

Trial quality and size insufficient to robustly and precisely identify a treatment effect.

Conclusions

Given the uncertainty of both the benefits and harms of MRAs in dialysis, large high-quality trials are required.