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Abstract: TH-PO441

Aldosterone Antagonists for Preventing the Progression of CKD: An Updated Cochrane Review

Session Information

Category: CKD (Non-Dialysis)

  • 2102 CKD (Non-Dialysis): Clinical, Outcomes, and Trials


  • Chung, Edmund YM, NSW Northern Sydney Health District, Lindfield, New South Wales, Australia
  • Palmer, Suetonia, University of Otago, Christchurch, New Zealand
  • Strippoli, Giovanni F.M., University of Bari, Bari, Italy

Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) reduce proteinuria and retard the progression of chronic kidney disease (CKD), though resolution of proteinuria may be incomplete. We evaluated whether addition of an aldosterone antagonist may further prevent progression of CKD.


We searched the Cochrane Kidney and Transplant Register of Studies through to 3 September 2018 for randomized controlled trials comparing aldosterone antagonists to standard care or placebo in patients with proteinuric CKD. Two independent authors extracted data for end-stage kidney disease (ESKD), major cardiovascular events, mortality, proteinuria, glomerular filtration rate (GFR), blood pressure, hyperkalemia, acute kidney injury (AKI), and gynecomastia. Risk of bias was assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE.


Forty-three studies (5171 participants) were eligible. Risk of bias in the evaluated methodological domains was unclear or high risk in most studies. Aldosterone antagonists had uncertain effects on risk of ESKD (2 studies, 84 participants, risk ratio [RR] 3.00, 95% confidence interval [CI] 0.33 to 27.65, very low certainty evidence), mortality (3 studies, 421 participants, RR 0.58, 95%CI 0.10 to 3.50, low certainty evidence), cardiovascular events (3 studies, 1067 participants, RR 0.95, 95%CI 0.26 to 3.56, low certainty evidence) and GFR (12 studies, 861 participants, MD -2.25 ml/min/1.73 m2, 95%CI -4.76 to 0.25, low certainty evidence); may reduce proteinuria (14 studies, 910 participants, standardized mean difference [SMD] -0.53, 95%CI -0.86 to -0.19, very low certainty evidence) but probably increases risk of hyperkalemia (17 studies, 2683 participants, RR 2.10, 95%CI 1.42 to 3.13, moderate certainty evidence), AKI (4 studies, 1088 participants, RR 2.02, 95%CI 1.02 to 4.02, moderate certainty evidence) and gynecomastia (4 studies, 281 participants, RR 5.14, 95% CI 1.14 to 23.23, moderate certainty evidence) compared to standard care or placebo.


Aldosterone antagonists when added to ACEi or ARB (or both) may reduce proteinuria but have uncertain effects on death, major cardiovascular events or ESKD and may incur excess hyperkalaemia, acute kidney injury and gynecomastia.