PRO/CON debate: non-steroidal versus steroidal mineralocorticoid receptor antagonists in chronic kidney disease: progress, pragmatism, and remaining uncertainties

Abstract Mineralocorticoid receptor antagonists (MRAs) are a central component of contemporary cardiorenal protection in chronic kidney disease (CKD). Classic steroidal MRAs, spironolactone and eplerenone, have long been used to treat hypertension and heart failure and to reduce albuminuria, but their wider use in CKD has been constrained by hyperkalaemia and endocrine side-effects. Non-steroidal MRAs (nsMRAs), typified by finerenone, were developed to maintain antiproteinuric and antifibrotic efficacy while improving tissue selectivity, pharmacokinetics and tolerability. Large outcome trials in type 2 diabetes with albuminuric CKD show that finerenone reduces the risk of kidney failure and major cardiovascular events when added to renin–angiotensin system (RAS) blockade and, more recently, in combination with SGLT2 inhibition. At the same time, the superior blood-pressure-lowering capacity, low cost and global availability of steroidal MRAs remain compelling, particularly in resistant hypertension and resource-constrained settings. This pro/con debate contrasts the case for nsMRAs with that for classic steroidal MRAs and explores how best to deploy each class across heterogeneous CKD populations.