What is the role of Finrenone (Finerenone) in the management of Chronic Kidney Disease (CKD)?

Role of Finerenone in Chronic Kidney Disease Management

Finerenone is strongly recommended for patients with chronic kidney disease and type 2 diabetes to reduce CKD progression and cardiovascular events, with evidence showing a 23% reduction in composite kidney outcomes and a 14% reduction in cardiovascular events across the spectrum of CKD severity. 1

Mechanism and Clinical Benefits

• Finerenone is a nonsteroidal mineralocorticoid receptor antagonist (MRA) that reduces kidney inflammation and fibrosis while offering more selective MR blockade than steroidal MRAs 2
• The FIDELITY pooled analysis (combining FIDELIO-DKD and FIGARO-DKD trials) demonstrated a 23% reduction in the composite kidney outcome (sustained ≥57% decrease in eGFR or renal death) with finerenone versus placebo (5.5% vs. 7.1%; HR 0.77 [95% CI 0.67–0.88]; P = 0.0002) 1
• Cardiovascular benefits include a 14% reduction in composite cardiovascular outcomes (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for heart failure) (12.7% vs. 14.4%; HR 0.86 [95% CI 0.78–0.95]; P = 0.0018) 1
• Heart failure hospitalization was notably reduced by 29% (HR 0.71 [95% CI 0.56–0.90]) 3, 1
• End-stage kidney disease was reduced by 36% (HR 0.64 [95% CI 0.41–0.995]) 1, 3
• Finerenone significantly reduced the risk of all-cause and cardiovascular mortality in patients with T2D and CKD while on treatment, as well as sudden cardiac death 4

Patient Selection and Eligibility

• Finerenone is indicated for patients with type 2 diabetes and CKD with:
  • eGFR 25-90 mL/min/1.73 m² 1
  • Elevated urinary albumin-to-creatinine ratio (UACR) ≥30 mg/g 1
• Benefits are observed across the spectrum of CKD severity, regardless of baseline HbA1c levels or insulin use 5
• Early albuminuria reduction with finerenone accounts for 84% of the treatment effect against CKD progression and 37% of the effect against cardiovascular outcomes 6

Dosing and Administration

• For patients with eGFR 25-60 mL/min/1.73 m², start with 10 mg once daily 1, 3
• For patients with eGFR >60 mL/min/1.73 m², start with 20 mg once daily 1, 3
• Dose increase from 10 to 20 mg once daily is recommended after 1 month if serum potassium is ≤4.8 mmol/L and eGFR remains stable 1

Safety Considerations and Monitoring

• Hyperkalemia is the primary safety concern, with incidence rates of 10.8% with finerenone versus 5.3% with placebo 1
• Despite increased hyperkalemia risk, discontinuation rates due to hyperkalemia were relatively low (1.2% in finerenone group versus 0.4-0.6% in placebo) 1
• Monitor serum potassium levels closely, particularly when initiating therapy 3, 7
• Patients should have serum potassium ≤4.8 mmol/L before initiating treatment 1

Combination Therapy

• Finerenone can be used alongside SGLT2 inhibitors for complementary cardiorenal protection 3, 7
• In the FIDELIO-DKD trial, 4.5% of participants were also taking SGLT2 inhibitors, suggesting safety of the combination 1
• Patients should already be on optimized renin-angiotensin system inhibitors (ACE inhibitors or ARBs) 7, 5
• Avoid triple therapy with ACE inhibitors and ARBs together with finerenone, as this increases risk of adverse events, particularly hyperkalemia 7, 1

Special Populations and Considerations

• Patients with heart failure with reduced ejection fraction were excluded from clinical trials, so evidence is stronger for those with preserved ejection fraction 3, 1
• Benefits appear consistent regardless of baseline HbA1c level and insulin use 5
• Consider nephrology referral when eGFR <30 mL/min/1.73 m² for management of advanced kidney disease 1

Clinical Algorithm for Use

1. Identify patients with type 2 diabetes and CKD with eGFR ≥25 mL/min/1.73 m² and UACR ≥30 mg/g 1
2. Ensure patients are on optimized RAS blockade (ACE inhibitor or ARB) 7, 5
3. Check baseline serum potassium (must be ≤4.8 mmol/L) 1
4. Initiate finerenone at appropriate dose based on eGFR 3, 1
5. Monitor serum potassium after 4 weeks 1, 3
6. Consider dose increase if serum potassium remains ≤4.8 mmol/L and eGFR is stable 1
7. Continue regular monitoring of renal function and serum potassium 3, 7