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Aldosteronantagonisten „revisited“

Aldosterone antagonists revisited

Zusammenfassung

Aldosteron und die Aktivierung des Mineralokortikoidrezeptors (MR) sind durch Induktion von Fibrose, Inflammation und Proteinurie pathophysiologisch an Entstehung und Fortschreiten der chronischen Nierenerkrankung („chronic kidney disease“, CKD) beteiligt. Klinische Studien liefern Hinweise, dass eine Ergänzung der Blockade des Renin-Angiotensin-Aldosteron-Systems (RAAS) durch ACE(„angiotensin-converting enzyme“)-Inhibitoren oder AT1(Angiotensin-II-Rezeptor Subtyp 1)-Blocker um die Aldosteronantagonisten (MR-Antagonisten, MRA) bei CKD das Auftreten ungünstiger Verläufe verringert. Insbesondere hat sich die Datenlage in Bezug auf den Einsatz des selektiven, nichtsteroidalen MRA Finerenon bei Patienten/Patientinnen mit Typ-2-Diabetes und CKD durch zwei große multizentrische Studien verbessert. Dabei zeigt Finerenon günstige Effekte auf renale und kardiovaskuläre Endpunkte bei einem akzeptablen Hyperkaliämierisiko. Dagegen ist die Datenlage in Bezug auf den Einsatz der älteren MRA Eplerenon und Spironolacton und die Rolle von MRA bei Patienten/Patientinnen mit nichtdiabetischer CKD derzeit weniger klar. Dieser Artikel gibt einen Überblick über die aktuellen Studiendaten zur Kardio- und Nephroprotektion durch MRA bei CKD und geht auf die Evidenzlage zu den einzelnen Wirkstoffgenerationen ein.

Abstract

Aldosterone and mineralocorticoid receptor (MR) activation are pathophysiologically involved in the development and progression of chronic kidney disease (CKD) by induction of fibrosis, inflammation and proteinuria. Clinical studies provide evidence that adding aldosterone antagonists (mineralocorticoid receptor antagonists, MRA) to the renin-angiotensin-aldosterone system (RAAS) block by angiotensin-converting enzyme inhibitors or angiotensin II receptor subtype 1 blockers reduces the incidence of adverse outcomes in CKD. In particular, two large multicenter trials have provided new evidence that the selective nonsteroidal MRA finerenone reduces adverse renal and cardiovascular outcomes with an acceptable risk profile for hyperkalemia in patients with type 2 diabetes and CKD. In contrast, the data situation is currently less clear regarding the use of the older MRA eplerenone and spironolactone and the role of MRA in patients with nondiabetic CKD. This article provides a review of the current trial data on cardioprotection and nephroprotection by MRA in CKD and reviews the evidence for each generation of MRA.

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Correspondence to Jutta Swolinsky.

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Interessenkonflikt

K. Schmidt-Ott hat Beratungshonorare der Firma Bayer AG erhalten. J. Swolinsky gibt an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Hermann Haller, Hannover

Joachim Hoyer, Marburg

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Swolinsky, J., Schmidt-Ott, K. Aldosteronantagonisten „revisited“. Nephrologie 17, 239–245 (2022). https://doi.org/10.1007/s11560-022-00576-9

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Schlüsselwörter

  • Mineralokortikoidrezeptorantagonisten
  • Aldosteron
  • Finerenon
  • Nephroprotektion
  • Chronische Niereninsuffizienz

Keywords

  • Mineralocorticoid receptor antagonists
  • Aldosterone
  • Finerenone
  • Nephroprotection
  • Chronic renal insufficiency