Marc Richards, MD is a nephrologist at Florida Kidney Physicians, LLC and Director of the FKP Glomerulonephritis Center of Excellence in Boca Raton, Florida.

Marc Richards, MD

Although inhibition of the renin-angiotensin system with angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), followed by sodium-glucose cotransporter 2 (SGLT2) inhibitors, has transformed

management by slowing disease progression, growing attention has shifted toward additional biological pathways that contribute to ongoing kidney and cardiovascular injury.

Among these, aldosterone has emerged as an increasingly important therapeutic target through the development of steroidal and nonsteroidal mineralocorticoid receptor antagonists, as well as newer aldosterone synthase inhibitors designed to reduce hormone production upstream.

, Marc Richards, MD, a nephrologist at Florida Kidney Physicians, discusses how advances in CKD pathophysiology have reshaped treatment over the past several decades, why aldosterone has become a key focus for clinicians, and what its physiologic role means for patients with kidney and cardiovascular disease.

Q&A: Why Aldosterone Has Become a Key Target in CKD Care, With Marc Richards, MD

Over the last couple of years and decades, our understanding of CKD pathophysiology has evolved considerably. Which biological pathways do you think have most changed the way clinicians approach treatment?

Richards: I think the big ones are really with ACE inhibitors, ARBs, and SGLT2 inhibitors; it's really all about tubuloglomerular feedback, reducing stress on the kidney.

And then also now we have a focus on targeting aldosterone as a way of trying to help limit stress on the kidney or limit stress on the heart, with older drugs like spironolactone and eplerenone, newer medicines like finerenone, and even looking into novel agents like aldosterone synthase inhibitors, which recently hit the market, to even prevent the aldosterone from being released in the first place.

Could you give a brief overview of aldosterone—what it does physiologically and why clinicians should pay attention to it?

Richards: Aldosterone is a hormone that's released by the adrenal gland, typically in response to either just being released on its own in cases of primary hyperaldosteronism, or in the setting of excess renin release, which can also increase that release because renin can stimulate that.

We know that aldosterone can lead to hypertension. It can lead to hypokalemia. It can lead to stress in patients with secondary release in patients with heart or liver dysfunction, and it probably has issues in the setting of—can possibly lead to—worsening renal dysfunction as well over time.

Editor’s Note: Richards reports no relevant disclosures.

National Institute of Diabetes and Digestive and Kidney Diseases. 

Kidney Disease Statistics for the United States

https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease

Fioretti F, Testani JM, Tio MC, Pitt B, et al. Aldosterone and aldosterone modulation in cardio-kidney diseases. 

. 2025;86(5):354-373. doi:10.1016/j.jacc.2025.06.012.

Articles

Chronic kidney disease therapeutics have historically centered on renin-angiotensin system blockade with ACE inhibitors and ARBs, later complemented by SGLT2 inhibitors to restore tubuloglomerular feedback and reduce intraglomerular stress. Attention is increasingly shifting toward aldosterone as an additional driver of ongoing renal and cardiovascular injury. Mineralocorticoid receptor antagonism now spans legacy steroidal agents, newer nonsteroidal options such as finerenone, and emerging aldosterone synthase inhibitors aimed at suppressing hormone production upstream, with implications for hypertension, hypokalemia, and progressive organ dysfunction.

Michael Richards, MD, discusses aldosterone's role in CKD pathophysiology and why targeting this pathway may reshape kidney disease treatment.