title: Mineralocorticoid receptor blockade in addition to angiotensin converting enzyme inhibitor or angiotensin II receptor blocker treatment: an emerging paradigm in diabetic nephropathy: a systematic review.
abstract: Blockade of the renin-angiotensin-aldosterone system (RAAS) is a standard therapeutic intervention in diabetic patients with chronic kidney disease (CKD). Concomitant mineralocorticoid receptor blockade has been studied as a novel approach to further slow down CKD progression. We used PubMed and EMBASE databases to search for relevant literature. We included in our review eight studies in patients of at least 18 years of age, with a diagnosis of type 1 or type 2 diabetes mellitus and diabetic nephropathy, under an angiotensin converting enzyme inhibitor (ACEI) and/or an angiotensin II receptor blocker (ARB) as standard treatment. A subset of patients in each study also received a mineralocorticoid receptor blocker (MRB) (either spironolactone or eplerenone) in addition to standard treatment. Combined treatment with a mineralocorticoid receptor blocker further reduced albuminuria by 23 to 61% compared with standard treatment. Estimated glomerular filtration rate values upon study completion slightly decreased under combined treatment. Blood pressure levels upon study completion were significantly lower with combined treatment in three studies. Hyperkalemia prevalence increased in patients under combined treatment raising dropout rate up to 17%. Therefore, combined treatment by an ACEI/ARB and a MRB may further decrease albuminuria in diabetic nephropathy. This effect may be due to the specific properties of the MRB treatment. Clinicians should regularly check potassium levels because of the increased risk of hyperkalemia. Available evidence should be confirmed by an adequately powered comparative trial of the standard treatment (ACEI or ARB) versus combined treatment by an ACEI/ARB and a MRB.
authors: General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland. Electronic address: thomas.mavrakanas@hcuge.ch.
authors: Thomas A
authors: TA
authors: Mavrakanas
authors: General Internal Medicine Division, Geneva University Hospitals, Geneva, Switzerland.
authors: Karim
authors: K
authors: Gariani
authors: Nephrology Division, Geneva University Hospitals, Geneva, Switzerland.
authors: Pierre-Yves
authors: PY
authors: Martin
mesh_terms: D000419:Albuminuria / Q000209:etiology; D057911:Angiotensin Receptor Antagonists / Q000627:therapeutic use*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use*; D003928:Diabetic Nephropathies / Q000150:complications / Q000188:drug therapy*; D004359:Drug Therapy, Combination / Q000379:methods; D000077545:Eplerenone; D005919:Glomerular Filtration Rate; D006801:Humans; D006947:Hyperkalemia / Q000139:chemically induced; D000451:Mineralocorticoid Receptor Antagonists / Q000627:therapeutic use*; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000188:drug therapy*; D013148:Spironolactone / Q000031:analogs & derivatives / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D057911:Angiotensin Receptor Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000451:Mineralocorticoid Receptor Antagonists; D013148:Spironolactone; D000077545:Eplerenone
keywords: Albuminuria; Blood pressure; Diabetic nephropathy; Glomerular filtration rate; Hyperkalemia; Mineralocorticoid receptor blockade