Physicians' Academy for Cardiovascular Education

MRA use not associated with worse kidney outcomes in HFrEF

Safety of continuing mineralocorticoid receptor antagonist treatment in patients with heart failure with reduced ejection fraction and severe kidney disease: data from Swedish Heart Failure Registry

Literature - Guidetti F, Lund LH, Benson L, et al. - Eur J Heart Fail. 2023 Oct 5 [Online ahead of print]. doi: 10.1002/ejhf.3049

Introduction and methods


MRAs are frequently underprescribed or discontinued in patients with HFrEF [1]—especially in those with CKD [2]—despite the strong level of evidence supporting their efficacy and safety, irrespective of baseline renal function [3-7].

Aim of the study

The authors evaluated the risk of renal outcomes, all-cause mortality, and all-cause hospitalization associated with MRA use across the eGFR spectrum in a large, real-world HFrEF cohort, including patients with severe CKD (i.e., eGFR <30 mL/min per 1.73 m²).


For this observational cohort study, data of 33,942 patients with HFrEF (EF <40%) who were enrolled in the Swedish Heart Failure Registry between 2012 and 2020 were collected. Dialysis at the index visit was an exclusion criterion. At the index date, MRA use and patients’ renal function were assessed.


The primary endpoint was a composite renal outcome of dialysis initiation, renal death, renal failure hospitalization, or hyperkalemia hospitalization after 1 year. Additional endpoints were all-cause mortality and all-cause hospitalization, both assessed at 1 year.

Main results


In a real-world Swedish cohort study, 51% of the HFrEF patients were prescribed an MRA and MRA use decreased with worsening renal function. However, MRA use was not associated with a higher risk of the composite renal outcome, all-cause mortality, and all-cause hospitalization at 1 year. The safety profile of MRAs was consistent across the eGFR spectrum and, notably, also in patients with severe CKD. The authors believe their “findings might suggest not to encourage MRA discontinuation in patients with severe CKD if strict laboratory surveillance is feasible.”


Show references

Find this article online at Eur J Heart Fail.

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