Review ArticlesMineralocorticoid Receptor Antagonist Use in Heart Failure With Reduced Ejection Fraction and End-Stage Renal Disease Patients on Dialysis A Literature ReviewBhinder, Jasjit MD*; Patibandla, Saikrishna MD†; Gupta, Chhaya A. MD*; Levine, Avi MD*; Gass, Alan L. MD*; Lanier, Gregg M. MD*Author Information From the *Division of Cardiology, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY †Department of Medicine, Brooklyn Hospital Center, Brooklyn, NY. Disclosure: The authors have no conflicts of interest to report. Correspondence: Gregg M. Lanier, MD, Westchester Medical Center, Macy Pavilion, Rm 110, 100 Woods Rd, Valhalla, NY 10595. E-mail: firstname.lastname@example.org. Cardiology in Review: May/June 2020 - Volume 28 - Issue 3 - p 107-115 doi: 10.1097/CRD.0000000000000286 Buy Metrics Abstract Mineralocorticoid receptor antagonists (MRAs) are known to have a proven mortality benefit in heart failure with reduced ejection fraction (HFrEF) without kidney disease. As patients with end-stage renal disease (ESRD) requiring either peritoneal dialysis or hemodialysis were excluded in clinical trials of HFrEF, the data are scant on the appropriate use of MRAs in this population. The unknown efficacy, along with concerns of adverse effects such as hyperkalemia, has limited the willingness of clinicians to consider using MRAs in these patients. However, it is unclear whether the risk of hyperkalemia is present if a patient is oliguric or anuric. Current guidelines recommend against the use of MRAs in patients with chronic kidney disease, but do not address the use of MRAs in patients requiring dialysis. This article will review the epidemiology of heart failure in ESRD, the pathophysiological derangements of the renin–angiotensin–aldosterone system in patients with kidney disease, and the results from case series and trials of the use of MRAs in ESRD with HFrEF. Although limited to several small trials using MRAs in peritoneal and hemodialysis patients with or without HFrEF, the current literature appears to show the potential for clinical benefits with little risk. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.