Efficacy and safety of mineralocorticoid receptor antagonists with ACEI/ARB treatment for diabetic nephropathy: A meta‐analysis

Background To explore the efficacy and safety of adding mineralocorticoid receptor antagonists (MRAs) to the treatment in diabetic nephropathy (DN) with ACEI/ARB. Methods We systematically searched the PubMed, Embase and Cochrane Library databases for randomised controlled trials up to November 1st 2018 that evaluated the effects of MRAs with ACEI/ARB treatment. Results The combination treatment of MRAs and ACEI/ARB further reduced urinary protein/albumin excretion compared with ACEI/ARB monotherapy (mean difference [MD], −44.17 [95% CIs, −61.73 to −26.61], P < .00001). Although no statistically significant changes in glomerular filtration rate were observed, the combination group significantly increased serum/plasma creatinine (MD, 7.40 [95% CIs, 4.69-10.11], P < .00001). Subgroup analysis based on generations of MRAs suggested a lower relative risk of hyperkalaemia with finerenone (relative risk, 2.22 [95% CIs, 0.13-38.13], P = .58) than eplerenone (relative risk, 2.81 [95% CIs, 1.03-7.69], P = .04) or spironolactone (relative risk, 4.58 [95% CIs, 2.60-8.08], P < .00001). Conclusion MRAs can significantly reduce proteinuria and increase blood creatinine in DN patients under blockade of the renin-angiotensin system. The combination treatment of finerenone and ACEI/ARB runs a lower risk of hyperkalaemia than eplerenone or spironolactone.