What is the role of finerenone (mineralocorticoid receptor antagonist) in treating a patient with chronic kidney disease (CKD) who is not diabetic?

Role of Finerenone in Non-Diabetic Chronic Kidney Disease

Finerenone is not currently recommended for patients with chronic kidney disease who do not have diabetes, as the existing evidence and guidelines only support its use in diabetic kidney disease. 1

Current Evidence and Recommendations

• Finerenone has only been studied and approved for patients with type 2 diabetes and chronic kidney disease with albuminuria, as demonstrated in the FIDELIO-DKD and FIGARO-DKD trials 1
• Current KDIGO guidelines specifically recommend nonsteroidal MRAs (finerenone) only for patients with type 2 diabetes who have persistent albuminuria (ACR >30 mg/g) and normal potassium levels despite maximum tolerated doses of RAS inhibitors 1
• The American Diabetes Association also limits its recommendation of finerenone to people with type 2 diabetes and CKD 1

Ongoing Research for Non-Diabetic CKD

• The FIND-CKD trial (NCT05047263) is currently investigating finerenone in non-diabetic CKD patients, but results are not yet available 2
• This phase 3 trial is enrolling adults with non-diabetic CKD with UACR ≥200-≤3500 mg/g and eGFR ≥25-<90 ml/min/1.73 m² 2
• The most common causes of CKD in the FIND-CKD trial are chronic glomerulonephritis (57.0%) and hypertensive/ischemic nephropathy (29.0%) 2

Mechanism and Potential Benefits

• Finerenone is a non-steroidal mineralocorticoid receptor antagonist with anti-inflammatory and anti-fibrotic effects that could theoretically benefit non-diabetic CKD 3
• In diabetic CKD, finerenone has shown:
  • Reduction in kidney failure progression (HR: 0.82,95% CI: 0.73–0.93) 1
  • Cardiovascular protection (HR: 0.86,95% CI: 0.78–0.95) 1
  • Reduction in heart failure hospitalizations (HR: 0.71,95% CI: 0.56–0.90) 1, 4

Current Treatment Approach for Non-Diabetic CKD

• For non-diabetic CKD patients, the current standard of care includes:
  • RAS inhibitors (ACEi or ARB) at maximum tolerated dose for patients with hypertension 1
  • SGLT2 inhibitors have shown benefits in non-diabetic CKD and are recommended for kidney protection 1
  • Diuretics and calcium channel blockers for blood pressure management 1

Safety Considerations

• Hyperkalemia is the main safety concern with finerenone (14% vs. 6.9% with placebo in diabetic CKD trials) 1
• Permanent discontinuation due to hyperkalemia occurred in 1.7% of patients on finerenone vs. 0.6% on placebo in diabetic CKD trials 1
• Careful monitoring of serum potassium would be essential if finerenone were to be used in non-diabetic CKD 4

Clinical Implications and Future Directions

• Until the results of the FIND-CKD trial are available, there is insufficient evidence to recommend finerenone for non-diabetic CKD 2, 3
• Small studies suggest potential benefits in advanced CKD with eGFR below 25 mL/min/1.73 m², but sample sizes are too small for definitive conclusions 5
• Future research may explore combination therapy with SGLT2 inhibitors in non-diabetic CKD, as 16.9% of patients in the FIND-CKD trial were already using SGLT2 inhibitors at baseline 2, 3

In conclusion, while finerenone has shown promising results in diabetic kidney disease, clinicians should wait for the results of dedicated trials like FIND-CKD before considering its use in non-diabetic CKD patients. Current treatment should focus on established therapies like RAS inhibitors and SGLT2 inhibitors for this population.