Nonsteroidal mineralocorticoid receptor antagonists and cardiorenal outcomes in chronic kidney disease.

The burden of adverse cardiorenal outcomes among patients with the trifecta of diabetes, heart failure (HF), and chronic kidney disease (CKD) remains high. Steroidal mineralocorticoid receptor antagonists (MRAs) have been shown to improve clinical outcomes in patients with HF; however, there is significant underutilization of these agents, especially in patients with advanced CKD. Non-steroidal MRAs are an emerging therapeutic option for patients with diabetic kidney disease and are now guideline-supported in this population. Nonsteroidal MRAs have a unique pharmacological profile distinct from their steroidal counterparts, that retains the class-specific cardiorenal benefits but may help mitigate adverse effects, especially hyperkalemia, in patients with CKD. In this review, we summarize the current evidence in the use of non-steroidal MRAs for improving cardiorenal outcomes in patients with CKD and diabetes, as well as for combination use alongside other foundational medical therapies used in HF and CKD.