Efficacy and safety of selective aldosterone synthase inhibitors for blood pressure reduction in patients with CKD: a meta-analysis of randomized controlled trials

Aldosterone synthase inhibitors (ASIs) demonstrated significant blood pressure (BP) lowering efficacy in patients with uncontrolled hypertension, but evidence in chronic kidney disease (CKD) remains limited. This meta-analysis explores the effects of selective ASIs on BP levels in CKD. Secondary outcomes were albuminuria (UACR), eGFR change and hyperkalemia incidence. Five RCTs (1,148 patients) were included; 2 used baxdrostat, 2 lorundrostat, and 1 study used vicadrostat. Treatment with ASIs was associated with a significant placebo-adjusted reduction in SBP of−7.9 mmHg [95% confidence interval (CI) −10.0 to −5.9, I ²  = 0%] and DBP of −3.1 mmHg (95% CI −5.9 to −0.2, I ²  = 62%) and reduced UACR by −31.7% (95% CI −54.5 to −8.9, I ²  = 91%). The pooled placebo-adjusted eGFR change was −2.05 ml/min/1.73 m ² (95% CI −3.15 to −0.95, I ²  = 0%). The risk of hyperkalemia was higher with ASIs, but with high heterogeneity (risk ratio, 4.04 [95% CI 0.94 to 17.35], I ²  = 76%). In conclusion, selective ASIs present a potential treatment option for BP control and albuminuria reduction in patients with CKD.