Mineralocorticoid receptor antagonist use in chronic kidney disease with type 2 diabetes: a clinical practice document by the European Renal Best Practice (ERBP) board of the European Renal Association (ERA).

Chronic kidney disease (CKD) in individuals with type 2 diabetes (T2D) represents a major public health issue; it develops in about 30%-40% of patients with diabetes mellitus and is the most common cause of CKD worldwide. Patients with CKD and T2D are at high risk of both developing kidney failure and of cardiovascular events. Renin-angiotensin system (RAS) blockers were considered the cornerstone of treatment of albuminuric CKD in T2D for more than 20 years. However, the residual risk of progression to more advanced CKD stages under RAS blockade remains high, while in major studies with these agents in patients with CKD and T2D no significant reductions in cardiovascular events and mortality were evident. Steroidal mineralocorticoid receptor antagonists (MRAs) are known to reduce albuminuria in individuals on RAS monotherapy, but their wide clinical use has been curtailed by the significant risk of hyperkalemia and absence of trials with hard renal outcomes. In recent years, non-steroidal MRAs have received increasing interest due to their better pharmacologic profile. Finerenone, the first compound of this class, was shown to effectively reduce the progression of kidney disease and of cardiovascular outcomes in participants with T2D in phase 3 trials. This clinical practice document prepared from a task force of the European Renal Best Practice board summarizes current knowledge on the role of MRAs in the treatment of CKD in T2D aiming to support clinicians in decision-making and everyday management of patients with this condition.

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© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.

Déclaration de conflit d'intérêts

M.K., F.M., I.N., M.C. and A.O. are all members of the CKJ editorial board. P.S. reports consultancy fees from AstraZeneca, Bayer, HealThink, Innovis Pharma, Menarini, PrimeView and ReCor Medical, and speaker fees from AiCME, Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Genesis Pharma, Menarini, PeerVoice, Springer and Win Medica; he has received research support from AstraZeneca, Boehringer Ingelheim, Elpen, and Servier; he was a member of steering committees and endpoint adjudication committees for Bayer trials. C.F. has received consultancy and speaker fees from Bayer. I.N. reports speaker fees from AstraZeneca, Boehringer-Ingelheim and Amgen. P.R. reports consulting for Idorsia, G3P, honoraria from AstraZeneca, Bayer, Boehringer-Ingelheim, Cincor, CVRx, Fresenius, KBP biosciences, Novartis, NovoNordisk, Relypsa, Servier and Vifor Fresenius Medical Care Renal Pharma; and travel grants from AstraZeneca, Bayer, CVRx, Novartis and Vifor Fresenius Medical Care Renal Pharma; Cofounder: CardioRenal. C.W. has received honoraria for consultancy and lecturing from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Fresenius Medical Care, GSK, Lilly, MSD, Novo-Nordisk and Vifor CSL. A.O. has received grants from Sanofi and consultancy or speaker fees or travel support from Adviccene, Alexion, Astellas, AstraZeneca, Amicus, Amgen, Boehringer Ingelheim, Fresenius Medical Care, GSK, Bayer, Sanofi-Genzyme, Menarini, Mundipharma, Kyowa Kirin, Lilly, Freeline, Idorsia, Chiesi, Otsuka, Novo-Nordisk, Sysmex and Vifor Fresenius Medical Care Renal Pharma, and is Director of the Catedra Mundipharma-UAM of DKD and the Catedra Astrazeneca-UAM of chronic kidney disease and electrolytes. He has stock in Telara Farma.