Селективные ингибиторы альдостеронсинтазы снижают давление и альбуминурию у пациентов с хронической болезнью почек

Selective aldosterone synthase inhibitors (ASIs) significantly lowered blood pressure and albuminuria among patients with chronic kidney disease (CKD), according to a meta-analysis of 5 randomized controlled trials involving 1148 participants published in the Journal of Hypertension. Compared with placebo, ASI therapy reduced systolic blood pressure by 7.9 mm Hg (95% CI, −10.0 to −5.9; I² = 0%) and diastolic blood pressure by 3.1 mm Hg (95% CI, −5.9 to −0.2; I² = 62%). However, treatment was also associated with increased hyperkalemia risk, particularly for severe events. “Across 5 randomized controlled trials, ASI treatment was associated with significant placebo-adjusted reductions in systolic blood pressure and diastolic blood pressure, accompanied by a significant reduction in urinary albumin-to-creatinine ratio,” investigators wrote. “Treatment was associated with a modest decline in estimated glomerular filtration rate (possibly reflecting an intraglomerular pressure reduction) and an increased risk of hyperkalemia.” Marieta Theodorakopoulou, MD, PhD, with Aristotle University of Thessaloniki, Thessaloniki, Greece, and colleagues screened 465 records and included 3 phase 2 randomized controlled trials conducted specifically in patients with CKD and 2 CKD subgroup analyses from phase 3 trials of uncontrolled or resistant hypertension. Two studies evaluated baxdrostat, 2 evaluated lorundrostat, and 1 evaluated vicadrostat. Four trials used parallel-group designs and 1 used a crossover design, with treatment periods ranging from 4 to 26 weeks. Three trials provided data for albuminuria and estimated glomerular filtration rate. ASI therapy produced a 31.7% placebo-adjusted reduction in urine albumin-to-creatinine ratio (95% CI, −54.5% to −8.9%; I² = 91%). The pooled placebo-adjusted estimated glomerular filtration rate change was −2.05 mL/min/1.73 m² (95% CI, −3.15 to −0.95; I² = 0%). Certainty of evidence was moderate for systolic BP reduction but low or very low for other outcomes because of heterogeneity, imprecision, and limited follow-up. Hyperkalemia was more frequent with ASIs, although estimates were imprecise and heterogeneous. The pooled risk ratio (RR) was 4.04 (95% CI, 0.94-17.35; I² = 76%). Severe hyperkalemia, defined as potassium of at least 6.0 mmol/L, was also more common with ASIs (RR, 4.25; 95% CI, 1.34-13.52; I² = 0%). Treatment discontinuation attributable to hyperkalemia was similarly increased (RR, 7.14; 95% CI, 1.35-37.67; I² = 0%). Sensitivity analyses supported the consistency of the systolic blood pressure findings. Excluding CKD subgroup analyses from broader hypertension trials yielded a 7.7 mm Hg systolic blood pressure reduction (95% CI, −10.1 to −5.4; I² = 0%). Leave-one-out analyses and analyses restricted to trials at low risk of bias produced comparable results. Overall risk of bias was low, although 1 trial available only as an abstract raised some methodological concerns. The investigators noted several limitations, including the small number of CKD-specific trials, reliance on aggregated rather than individual-level data, short follow-up, and substantial heterogeneity for urine albumin-to-creatinine ratio and hyperkalemia. All studies used office rather than ambulatory blood pressure measurements, and investigators could not formally assess publication bias. Longer CKD-specific trials are necessary to determine whether ASI-associated reductions in BP and albuminuria translate into durable kidney and cardiovascular benefits. “These findings suggest that selective ASIs represent a potential treatment option for BP control and albuminuria reduction in patients with CKD,” explained Theodorakopoulou and colleagues. “Larger [randomized controlled trials] assessing the long-term kidney and cardiovascular efficacy and safety of these agents are awaited.” No financial support was listed for this study, and the authors did not report any conflicts of interest. Please see the original reference for full disclosures. References: Theodorakopoulou M, Iatridi F, Theodosiadi A, Hecking M, Strippoli G, Sarafidis P. Efficacy and safety of selective aldosterone synthase inhibitors for blood pressure reduction in patients with CKD: a meta-analysis of randomized controlled trials. J Hypertens. Published online July 24, 2026. doi:10.1097/HJH.0000000000004399