What is the use of Kerendia (finerenone) 10 mg in chronic kidney disease (CKD) with type 2 diabetes?

Kerendia (Finerenone) 10 mg in Chronic Kidney Disease with Type 2 Diabetes

Finerenone 10 mg is recommended for patients with type 2 diabetes and chronic kidney disease with albuminuria who are already on maximum tolerated doses of ACE inhibitors or angiotensin receptor blockers to improve cardiovascular outcomes and reduce the risk of CKD progression. 1

Indications and Benefits

Finerenone is a non-steroidal mineralocorticoid receptor antagonist (MRA) specifically indicated for:

• Type 2 diabetes patients with CKD and albuminuria (>30 mg/g) 1, 2
• eGFR ≥25 ml/min/1.73 m² 1, 2
• Patients already receiving maximum tolerated doses of RAS inhibitors (ACEIs or ARBs) 1

Clinical Benefits

• 13-14% reduction in composite cardiovascular events (HR 0.86,95% CI: 0.78-0.95) 2, 3
• 23% reduction in composite renal events (HR 0.77,95% CI: 0.67-0.88) 2, 3
• 36% reduction in end-stage renal disease (HR 0.64,95% CI: 0.41-0.995) 2
• Reduces new-onset heart failure by 32% (HR 0.68,95% CI: 0.50-0.93) 4
• Reduces hospitalization for heart failure by 29% (HR 0.71,95% CI: 0.56-0.90) 4

Dosing Protocol

Initial Dosing

• 10 mg once daily for patients with eGFR 25-60 ml/min/1.73 m² 1, 2
• 20 mg once daily for patients with eGFR >60 ml/min/1.73 m² 1, 2

Dose Titration

• After 4 weeks, if serum potassium remains ≤4.8 mmol/L and eGFR is stable, increase 10 mg dose to 20 mg once daily 1, 2

Patient Selection and Monitoring

Pre-Treatment Requirements

• Verify serum potassium is ≤4.8 mmol/L before initiating treatment 1, 2
• Ensure patient is on maximum tolerated dose of RAS inhibitor (ACEI or ARB) 1
• Confirm eGFR ≥25 ml/min/1.73 m² 1, 2

Monitoring Schedule

• Check serum potassium and renal function at 1 month after initiation 1, 2
• Continue monitoring every 4 months thereafter 1, 2
• Additional monitoring after any dose change 2

Management of Hyperkalemia

Hyperkalemia is the primary adverse effect (10.8% with finerenone vs 5.3% with placebo) 2, 3

Protocol for Hyperkalemia Management:

• For K+ ≤4.8 mmol/L: Continue current dose
• For K+ 4.9-5.5 mmol/L: Continue current dose but monitor more closely
• For K+ >5.5 mmol/L:
  • Hold finerenone
  • Consider adjustments to diet or concomitant medications
  • Recheck K+
  • Consider reinitiation at 10 mg daily when K+ ≤5.0 mmol/L 1, 2

Combination Therapy

Finerenone can be effectively combined with:

• SGLT2 inhibitors (which are first-line therapy for T2D with CKD) 1, 2
• GLP-1 receptor agonists with proven cardiovascular benefits 1
• Metformin (if eGFR remains >30 mL/min/1.73 m²) 1

Clinical Pearls and Caveats

• Key Mechanism: Finerenone reduces albuminuria, which mediates 84% of its kidney protection effect and 37% of its cardiovascular benefit 5
• Patient Selection: Most appropriate for high-risk patients with persistent albuminuria despite standard therapies 1
• Exclusions: Avoid in patients with serum potassium >4.8 mmol/L or eGFR <25 mL/min/1.73 m² 1, 2
• Advantage over Steroidal MRAs: Does not cause gynecomastia (unlike spironolactone) and has more balanced cardio-renal effects 6
• Monitoring Pitfall: Failure to check potassium levels at appropriate intervals can lead to dangerous hyperkalemia 1, 2

Finerenone represents an important addition to the therapeutic arsenal for patients with type 2 diabetes and CKD, offering significant reductions in both kidney disease progression and cardiovascular events when added to standard therapy.