Finerenone in Chronic Kidney Disease with Type 2 Diabetes
Finerenone is strongly indicated for patients with chronic kidney disease (CKD) and type 2 diabetes who have persistent albuminuria (>30 mg/g) despite maximum tolerated renin-angiotensin-aldosterone system (RAS) inhibitor therapy, with proven benefits in reducing kidney disease progression and cardiovascular events. 1
Patient Selection Criteria
Finerenone therapy is appropriate for patients who meet the following criteria:
- Type 2 diabetes with CKD
- Persistent albuminuria (>30 mg/g)
- Already on maximum tolerated RAS inhibitor therapy
- eGFR ≥25 mL/min/1.73 m²
- Baseline serum potassium ≤4.8 mmol/L 1
Dosing Recommendations
Dosing should be based on kidney function:
- eGFR 25-59 mL/min/1.73 m²: 10 mg once daily
- eGFR ≥60 mL/min/1.73 m²: 20 mg once daily 1
Contraindications and Precautions
Finerenone should not be initiated in patients with:
- Adrenal insufficiency
- eGFR <25 mL/min/1.73 m²
- Serum potassium >4.8 mmol/L 1
Monitoring Requirements
- Check serum potassium at baseline
- Recheck at 1 month after initiation
- Continue monitoring every 4 months thereafter
- Target serum potassium level ≤4.8 mmol/L
- Hold finerenone if serum potassium >5.5 mmol/L 1
Clinical Benefits
Finerenone has demonstrated significant benefits in patients with CKD and type 2 diabetes:
- Kidney disease progression: 23% reduction (HR 0.77,95% CI: 0.67-0.88)
- Cardiovascular events: 14% reduction (HR 0.86,95% CI: 0.78-0.95)
- Hospitalization for heart failure: 29% reduction (HR 0.71,95% CI: 0.56-0.90) 1
The FIGARO-DKD trial specifically showed that finerenone reduced the risk of hospitalization for heart failure by 29% compared to placebo (HR 0.71,95% CI: 0.56-0.90) 2. Additionally, finerenone reduced the risk of new-onset heart failure by 32% (HR 0.68,95% CI: 0.50-0.93) 2.
Advantages of Nonsteroidal MRAs
Finerenone, as a nonsteroidal mineralocorticoid receptor antagonist (MRA), offers several advantages over steroidal MRAs:
- More balanced tissue distribution between heart and kidney
- More potent anti-inflammatory and anti-fibrotic effects
- Lower risk of hyperkalemia
- Minimal hormonal side effects 1
Combination Therapy
Finerenone can be effectively combined with other medications for additive cardiorenal protection:
- SGLT2 inhibitors (no dose adjustment required)
- GLP-1 receptor agonists
- Metformin (if eGFR >30 mL/min/1.73 m²) 1
Hyperkalemia Risk Management
The risk of hyperkalemia with finerenone is lower than with steroidal MRAs but still requires monitoring:
- Incidence of hyperkalemia: 10.8% with finerenone vs. 5.3% with placebo in FIGARO-DKD
- Discontinuation due to hyperkalemia: 2.3% with finerenone vs. 0.9% with placebo in FIDELIO-DKD 1
- In clinical trials, treatment-emergent adverse events were balanced between finerenone and placebo groups 2
Clinical Pearls and Pitfalls
- Always ensure patients are on maximum tolerated RAS inhibitor therapy before initiating finerenone
- Monitor potassium levels carefully, especially in patients with risk factors for hyperkalemia
- Do not initiate in patients with severely reduced kidney function (eGFR <25 mL/min/1.73 m²)
- Benefits are consistent across different eGFR and albuminuria categories 3
- Blood pressure reduction accounts for only a small proportion (12-14%) of finerenone's cardiorenal benefits 4