Diabetic nephropathy is defined as a decline in the renal function and an increase in the
amount of albuminuria (>300 mg/day). The interruption of the renin-angiotensin-aldosterone system
(RAAS) by well-established therapies such as angiotensin-converting enzyme inhibitor, angiotensin
receptor blockers, calcium channel blockers or diuretics has been beneficial in reducing the
progression of renal diseases; however, there is an increase in the levels of aldosterone due to the
aldosterone escape phenomenon. Newer and novel approaches to counteract this aldosterone breakthrough
while accentuating the anti-hypertensive and anti-proteinuric effects of these agents would
be ideal and mineralocorticoid receptor antagonists fit in this slot perfectly. This review attempted
to evaluate the safety and efficacy of and mineralocorticoid receptor antagonists for diabetic nephropathy.
Presently mineralocorticoid receptor antagonists such as spironolactone, eplerenone and
finerenone are being investigated as both monotherapies and as additional therapies. Clinical studies
have shown that these drugs have been effective in the reduction of blood pressure, urinaryalbumin-
excretion and estimated glomerular filtration rate. The commonly observed adverse effects
are hyperkalemia, gynaecomastia and vaginal bleeding, that are bothersome with spironolactone
seems to be avoidable if these patients are switched to non-steroidal and mineralocorticoid receptor
antagonists such as finerenone and eplerenone. Most of the studies have only evaluated the shortterm
effects of mineralocorticoid receptor antagonists on diabetic nephropathy. Hard outcomes such
as cardiovascular events, creatinine doubling, progression to end-stage renal disease, mortality and
the need for temporary or permanent dialysis need to be studied with these molecules.
Mineralocorticoid Receptor Antagonists in End-Stage Renal Disease: Efficacy and Safety