Steroidal MRAs Ineffective and Risky in Kidney Transplant Recipients: Study

Researchers have found in a new study steroidal mineralocorticoid receptor antagonists (MRAs) show no superior efficacy over placebo in kidney transplant recipients and are linked to a fourfold increased risk of hyperkalemia, even with preserved kidney function.

In patients with chronic kidney disease, mineralocorticoid receptor antagonists (MRAs) exert a reno-protective effect through its anti-inflammatory and antifibrotic effects. Less is known about the efficacy of MRAs in kidney transplant (KT) recipients. This meta-analysis aims to systematically assess the efficacy of MRAs in KT recipients. PubMed, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) that compared MRAs to placebo in KT recipients and reported the outcomes of (1) glomerular filtration rate (GFR); (2) serum creatinine; (3) systolic (SBP) and diastolic blood pressure (DBP); (4) hyperkalemia; and (5) interstitial fibrosis and tubular atrophy (IFTA) scores. Heterogeneity was examined with I2 statistics. A random-effects model was used for outcomes with high heterogeneity. Results: They included 5 RCTs with 293 patients, of whom 142 (48.5%) underwent treatment with a steroidal MRA. Mean follow-up ranged from 5 days to 36 months. There was no significant difference in GFR (MD 9.04 mL/min/1.73 m2; 95% CI − 2.76–20.85; p = 0.13) and serum creatinine between placebo and MRA groups (MD − 0.21 mg/dL; 95% CI − 0.62–0.20; p = 0.32). SBP (MD 0.69 mmHg; 95% CI − 0.69–2.08; p = 0.33), DBP (MD 0.45 mmHg; 95% CI − 0.69–1.59; p = 0.44) and IFTA scores exhibited no differences between groups (mild IFTA RR 1.21; 95% 0.83–1.74; p = 0.32) (moderate IFTA RR 0.82; 95% CI 0.45–1.50; P = 0.51) (severe IFTA RR 0.64; 95% CI 0.24–1.76; p = 0.39). MRAs were associated with a 4-fold increase in the risk of hyperkalemia compared with placebo (RR 4.06; 95% CI 1.46–11.28; p = 0.007). Steroidal MRAs have no superior efficacy compared with placebo in KT recipients and are associated with a 4-fold increase in the risk of hyperkalemia despite preserved kidney function.