What is the role of Finerenone in managing chronic kidney disease or heart failure?

Role of Finerenone in Managing Chronic Kidney Disease and Heart Failure

Finerenone is strongly recommended for patients with type 2 diabetes and chronic kidney disease with albuminuria (ACR ≥30 mg/g) who are already on maximum tolerated doses of ACE inhibitors or angiotensin receptor blockers to reduce the risk of CKD progression and cardiovascular events, particularly heart failure. 1, 2

Mechanism and Benefits

Finerenone is a nonsteroidal, selective mineralocorticoid receptor antagonist (MRA) that:

• Blocks mineralocorticoid receptor-mediated sodium reabsorption in the kidney
• Reduces overactivation of mineralocorticoid receptors in the heart and blood vessels 2
• Demonstrates significant cardiorenal protective effects:
  • 23% reduction in kidney disease progression (HR 0.77,95% CI: 0.67-0.88) 1, 2
  • 14% reduction in composite cardiovascular events (HR 0.86,95% CI: 0.78-0.95) 1
  • 29% reduction in hospitalization for heart failure (HR 0.71,95% CI: 0.56-0.90) 1, 2

Patient Selection Criteria

Finerenone is indicated for patients with:

• Type 2 diabetes with chronic kidney disease
• Persistent albuminuria (ACR ≥30 mg/g [≥3 mg/mmol])
• eGFR ≥25 ml/min/1.73 m²
• Serum potassium <4.8 mmol/L
• Already on maximum tolerated doses of ACE inhibitors or ARBs 1, 2

Dosing Protocol

• Initial dosing based on baseline renal function:
  • eGFR 25-60 ml/min/1.73 m²: 10 mg once daily
  • eGFR >60 ml/min/1.73 m²: 20 mg once daily
• 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

Monitoring Requirements

• Check serum potassium and renal function:
  • At baseline
  • 1 month after initiation
  • Every 4 months thereafter 2
• Discontinue if:
  • Serum potassium >5.5 mmol/L despite medical management
  • Severe hyperkalemia requiring emergency intervention occurs 2

Safety Profile

• Hyperkalemia is the primary adverse effect:
  • Incidence: 10.8% with finerenone vs. 5.3% with placebo in FIGARO-DKD
  • Discontinuation rate due to hyperkalemia: only 1.2% in clinical trials 1, 2
• Finerenone has fewer hormonal side effects compared to steroidal MRAs like spironolactone 3

Combination Therapy

Finerenone can be effectively combined with:

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

Clinical Implementation Algorithm

1. Identify eligible patients: Type 2 diabetes with CKD and albuminuria (ACR ≥30 mg/g)
2. Verify prerequisites:
   • Maximum tolerated dose of ACEi/ARB
   • eGFR ≥25 ml/min/1.73 m²
   • Serum K+ <4.8 mmol/L
3. Initiate appropriate dose based on eGFR
4. Monitor at 4 weeks for K+ and eGFR stability
5. Uptitrate if appropriate (10 mg → 20 mg)
6. Continue monitoring every 4 months
7. Consider combination with SGLT2i for additive cardiorenal protection

Important Caveats

• No direct comparison studies between finerenone and SGLT2 inhibitors exist; they can be used together for additive benefits 1
• Finerenone is contraindicated in patients with adrenal insufficiency 2
• Patients with heart failure with reduced ejection fraction were excluded from the major trials 1
• The benefits of finerenone are seen regardless of baseline ASCVD history 1

Finerenone represents an important addition to the therapeutic armamentarium for cardiorenal protection in patients with type 2 diabetes and CKD, with proven benefits on both kidney and cardiovascular outcomes.