Hypertension is the leading risk factor for premature death. The optimal treatment of low-renin hypertension (LRH), present in 30% of hypertensive individuals, is not known. LRH likely reflects a state of excess salt, expanded volume and/or mineralocorticoid receptor (MR) activation. Therefore, targeted treatment with MR antagonists (MRA) may be beneficial. The objective of this systematic review was to assess the efficacy of MRA therapy in LRH. MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials of adults with LRH that compared the efficacy of MRA to placebo or other antihypertensive treatments. Risk of bias was assessed using the Cochrane risk of bias tool. A meta-analysis was performed using a random-effects model to estimate the difference in blood pressure and the certainty of evidence was assessed using the GRADE approach. The protocol is registered on PROSPERO (CRD42022318763). From the 1612 records identified, 17 studies met the inclusion criteria with a total sample size of 1043 participants. Seven studies (n = 345) were assessed as having a high risk of bias. Meta-analysis indicated that MRA reduced systolic blood pressure by −6.8 mmHg (95% confidence interval −9.6 to −4.1) and −4.8 mmHg (95% confidence interval −11.9 to 2.4) compared to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) and diuretics. The certainty of the evidence was assessed as moderate and very low, respectively. The findings of this systematic review suggest that MRA is effective in lowering blood pressure in LRH and may be better than ACEi/ARB. Translation to clinical practice is limited by the uncertainty of evidence.

高血压是过早死亡的主要危险因素。30% 的高血压患者存在低肾素高血压 (LRH)，但其最佳治疗方法尚不清楚。LRH 可能反映了盐过量、体积扩大和/或盐皮质激素受体 (MR) 激活的状态。因此，MR 拮抗剂 (MRA) 的靶向治疗可能是有益的。本系统评价的目的是评估 MRA 治疗 LRH 的疗效。在 MEDLINE、Embase 和 Cochrane 数据库中检索了成人 LRH 的随机对照试验，这些试验比较了 MRA 与安慰剂或其他抗高血压治疗的疗效。使用 Cochrane 偏倚风险工具评估偏倚风险。使用随机效应模型进行荟萃分析来估计血压差异，并使用 GRADE 方法评估证据的确定性。该协议已在 PROSPERO 上注册（CRD42022318763）。在确定的 1612 条记录中，有 17 项研究符合纳入标准，总样本量为 1043 名参与者。七项研究 (n = 345) 被评估为具有高偏倚风险。荟萃分析表明，与血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂相比，MRA 使收缩压降低了 -6.8 mmHg（95% 置信区间 -9.6 至 -4.1）和 -4.8 mmHg（95% 置信区间 -11.9 至 2.4） （ACEi/ARB）和利尿剂。证据的质量分别被评估为中等和非常低。本系统评价的结果表明，MRA 可有效降低 LRH 患者的血压，并且可能优于 ACEi/ARB。临床实践的转化受到证据的不确定性的限制。