title: Aldosterone blockade and the mineralocorticoid receptor in the management of chronic kidney disease: current concepts and emerging treatment paradigms.
abstract: The past two decades have witnessed a striking paradigm shift with respect to our understanding of the widespread effects of aldosterone. There is substantive evidence that mineralocorticoid receptor (MR) activation promotes myriad 'off target' effects on the heart, the vasculature, and importantly the kidney. In the present review, we summarize the expanding role of MR activation in promoting both vascular and renal injury. We review the recent clinical studies that investigated the efficacy of MR antagonism (MRA) in reducing proteinuria and attenuating progressive renal disease. We also review in-depth both the utility and safety of MRA in the end-stage renal disease (ESRD) patient undergoing dialysis. Because the feasibility of add-on MRA is critically dependent on our ability to minimize or avoid hyperkalemia, and because controversy centers on the incidence of hyperkalemia, we critically review the risk of hyperkalemia with add-on MRA. Our present analysis suggests that hyperkalemia supervening in MRA-treated patients is overstated. Furthermore, recent studies demonstrating the efficacy of new non-absorbed, orally administered, potassium [K+]-binding polymers suggest that a multi-pronged approach encompassing adequate surveillance, moderate or low-dose MRA, and K-binding polymers may adequately control serum K in both chronic kidney disease and ESRD patients.
authors.affiliation: Adult Nephrology Unit, Department of Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.
authors.forename: Linda
authors.initials: L
authors.lastname: Shavit
authors.affiliation: Adult Nephrology Unit, Department of Medicine, Shaare Zedek Medical Center, Jerusalem, Israel; Division of Nephrology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
authors.forename: Meyer D
authors.initials: MD
authors.lastname: Lifschitz
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address: murraye@gate.net.
authors.forename: Murray
authors.initials: M
authors.lastname: Epstein
mesh_terms: D000450:Aldosterone / Q000097:blood / Q000378:metabolism*; D000818:Animals; D002614:Chelating Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D018450:Disease Progression; D006801:Humans; D006947:Hyperkalemia / Q000097:blood / Q000209:etiology / Q000517:prevention & control; D007668:Kidney / Q000187:drug effects* / Q000378:metabolism / Q000503:physiopathology; D007676:Kidney Failure, Chronic / Q000188:drug therapy / Q000378:metabolism / Q000503:physiopathology / Q000628:therapy*; D000451:Mineralocorticoid Receptor Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D011188:Potassium / Q000097:blood; D018161:Receptors, Mineralocorticoid / Q000378:metabolism; D006435:Renal Dialysis / Q000009:adverse effects; D018570:Risk Assessment; D012307:Risk Factors; D015398:Signal Transduction / Q000187:drug effects; D016896:Treatment Outcome
chemical_list: D002614:Chelating Agents; D000451:Mineralocorticoid Receptor Antagonists; D018161:Receptors, Mineralocorticoid; D000450:Aldosterone; D011188:Potassium