What is the treatment regimen for patients with chronic kidney disease (CKD) associated with type 2 diabetes using Kerendia (finerenone)?

Kerendia (Finerenone) Treatment Regimen for CKD Associated with Type 2 Diabetes

For patients with chronic kidney disease and type 2 diabetes who have albuminuria (UACR ≥30 mg/g) despite maximum tolerated renin-angiotensin system blockade, start finerenone at 10 mg once daily if eGFR is 25-60 mL/min/1.73 m², or 20 mg once daily if eGFR is >60 mL/min/1.73 m², with uptitration to 20 mg after 1 month if serum potassium remains ≤4.8 mmol/L. 1

Patient Eligibility Criteria

Before initiating finerenone, verify the following requirements:

• Albuminuria present: UACR ≥30 mg/g despite standard care 1
• eGFR threshold: Must be ≥25 mL/min/1.73 m² 1, 2
• Potassium level: Must be ≤4.8 mmol/L at baseline 3, 1
• RAS inhibitor optimization: Patient must already be on maximum tolerated dose of ACE inhibitor or ARB 3, 1

The FIDELIO-DKD trial enrolled patients with either UACR 30-300 mg/g with eGFR 25-60 mL/min/1.73 m² plus diabetic retinopathy, or UACR 300-5,000 mg/g with eGFR 25-75 mL/min/1.73 m² 3. The FIGARO-DKD trial included patients with UACR 30-300 mg/g and eGFR 25-90 mL/min/1.73 m², or UACR 300-5,000 mg/g and eGFR ≥60 mL/min/1.73 m² 4.

Initial Dosing Algorithm

For eGFR 25-60 mL/min/1.73 m²:

• Start with 10 mg once daily 3, 1

For eGFR >60 mL/min/1.73 m²:

• Start with 20 mg once daily 3, 1

Dose Uptitration Protocol

After 1 month of treatment, increase from 10 mg to 20 mg once daily if all of the following conditions are met 3, 1:

• Serum potassium remains ≤4.8 mmol/L 3, 1
• eGFR is stable 3, 1
• Medication is well-tolerated 1

Potassium Monitoring and Management

Monitoring schedule:

• Check potassium at 1 month, then periodically throughout treatment 1, 2

Management based on potassium levels:

• Potassium ≤5.5 mmol/L: Continue finerenone at current dose 1
• Potassium >5.5 mmol/L: Withhold finerenone temporarily 1
• When potassium returns to ≤5.0 mmol/L: Restart at 10 mg daily 1

This approach is critical because hyperkalemia occurred in 10.8% of finerenone patients versus 5.3% on placebo in FIGARO-DKD 4. However, only 1.2-2.3% of patients discontinued due to hyperkalemia, and no deaths related to hyperkalemia occurred in either trial 3, 4, 1.

Positioning in Treatment Algorithm

Finerenone should be added as second-line therapy after SGLT2 inhibitors 2. The KDIGO guidelines position SGLT2 inhibitors as first-line therapy for preventing CKD progression and cardiovascular events 2. Add finerenone when:

• Patient is already on an SGLT2 inhibitor and optimized RAS inhibition 2
• Residual albuminuria persists (UACR ≥30 mg/g) 2
• Serum potassium ≤4.8 mmol/L and can be monitored 2

This sequencing is important because only 4.5% of FIDELIO-DKD participants were on SGLT2 inhibitors at baseline 3, whereas current guidelines strongly recommend SGLT2 inhibitors as foundational therapy 2.

Expected Clinical Benefits

Kidney outcomes:

• 18% reduction in kidney disease progression (HR 0.82,95% CI 0.73-0.93) 3, 2
• 36% reduction in end-stage kidney disease (HR 0.64,95% CI 0.41-0.995) 4
• Early albuminuria reduction mediated 84% of the treatment effect on kidney outcomes 5

Cardiovascular outcomes:

• 13% reduction in cardiovascular death, MI, stroke, or heart failure hospitalization (HR 0.86-0.87) 3, 4, 2
• 29% reduction in heart failure hospitalizations (HR 0.71,95% CI 0.56-0.90) 4

These benefits are consistent regardless of baseline HbA1c level or insulin use 6.

Common Pitfalls to Avoid

Do not delay initiation due to concerns about hyperkalemia if baseline potassium is ≤4.8 mmol/L—the safety profile was excellent in trials with appropriate monitoring 4, 7. Do not use finerenone as monotherapy—it must be added to optimized RAS blockade 3, 1. Do not extrapolate data from steroidal MRAs (spironolactone, eplerenone) to finerenone, as they are different drug classes 3.