Can mineralocorticoid receptor antagonists reduce heart events in dialysis patients?
Mineralocorticoid receptor antagonists (MRAs) are drugs that block aldosterone, a hormone that can damage the heart and kidneys. In people on dialysis, heart problems are the leading cause of death. Research suggests MRAs can help prevent some heart events, but they also come with risks. The short answer is that MRAs likely reduce nonfatal heart events, but their effect on survival is less clear, and side effects like dangerously high potassium levels are a concern.
What the research says
A 2025 systematic review and meta-analysis of 14 randomized controlled trials involving 4,525 dialysis patients found that MRAs significantly reduced nonfatal cardiovascular events by about 32% (risk ratio 0.68). However, they did not significantly lower cardiovascular mortality or all-cause mortality, though there was a trend toward benefit 1. The same analysis showed MRAs significantly increased the risk of severe hyperkalemia (high potassium) by 35% and also raised the risk of gynecomastia (breast tenderness or enlargement) 1.
Earlier research supports these findings. A 2016 review noted that a large trial found a 3-year mortality rate of 6.4% in dialysis patients taking spironolactone 25 mg daily versus 19.7% in those not taking an MRA, without a significantly increased risk of hyperkalemia 6. That trial suggested a survival benefit, but the more recent meta-analysis did not confirm a statistically significant reduction in mortality 1.
A 2024 review on MRAs for hypertension and chronic kidney disease highlights that while MRAs have beneficial effects on heart and kidney conditions, their use is limited by side effects like hyperkalemia and kidney dysfunction. Newer non-steroidal MRAs may be more effective and safer, but they are not yet well-studied in dialysis patients 7.
Importantly, the evidence for MRAs in dialysis patients is not as strong as for other heart medications. For example, a large network meta-analysis of diabetes drugs found that SGLT-2 inhibitors and GLP-1 receptor agonists reduce cardiovascular events with high certainty, but that analysis did not focus on dialysis patients 5. So while MRAs show promise, they are not a standard therapy for everyone on dialysis.
What to ask your doctor
- Could an MRA like spironolactone or eplerenone be right for my heart health, given my potassium levels and dialysis schedule?
- How often would I need blood tests to check for high potassium if I start an MRA?
- Are there newer non-steroidal MRAs that might be safer for me?
- What signs of hyperkalemia or other side effects should I watch for?
- Would other heart medications, like beta-blockers or SGLT-2 inhibitors, be a better option for me?
This question is drawn from common patient questions about Nephrology and answered using cited medical research. We do not provide individualized advice.