The number of patients living with chronic kidney diseases is increasing, and so are the patients with end-stage renal disease (ESRD) undergoing renal replacement therapy (RRT). While there is a common understanding that these patients face higher risks of fatal or non-fatal cardiovascular and cerebrovascular events, and mineralocorticoid receptor antagonists (MRA) have been an essential pillar in managing heart failure, their use in this subset of patients have been overshadowed due to concerns of hyperkalemia. ESRD patients under RRT have often been excluded from landmark trials. This meta-analysis was conducted based on the PRISMA guideline after registering the protocol with PROSPERO (CRD42024499835). A database search included articles until April 2024 and relevant data extracted from the included studies. Analysis was done using RevMan web (version 5.4). A total of 15 studies among 1086 studies were included in the final analysis. Our meta-analysis revealed MRA significantly reduced all-cause mortality (OR 0.35, CI 0.23- 0.54) and cardio-vascular mortality (OR 0.37, 0.21-0.65). With some possible increase in the risk of hyperkalemia (OR 1.56, CI 1.01-2.42), with no discernible difference in the occurrence of stroke (OR 0.57, CI 0.25-1.28) or MI (OR 0.63, CI 0.08-4.72). The utilization of MRA in patients with ESRD under dialysis is linked to improved mortality outcomes, albeit with slight concerns for hyperkalemia. While current evidence leans towards MRA usage, prospective randomized controlled trials involving a broader patient cohort are essential to establish robust guidance for MRA application in this subset of patients.
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