What is the recommended usage of Finerenone for patients with chronic kidney disease (CKD) and heart failure?

Finerenone for Chronic Kidney Disease and Heart Failure

Finerenone should be initiated at 10-20 mg once daily in patients with type 2 diabetes, chronic kidney disease (eGFR ≥25 mL/min/1.73 m²), and persistent albuminuria (UACR ≥30 mg/g) despite maximum tolerated RAS inhibitor therapy, as it reduces both cardiovascular events and CKD progression, including heart failure hospitalizations. 1

Patient Selection Criteria

Eligible patients must meet ALL of the following:

• Type 2 diabetes with chronic kidney disease and albuminuria (UACR ≥30 mg/g) 2, 1
• eGFR ≥25 mL/min/1.73 m² (specifically 25-90 mL/min/1.73 m²) 2, 1
• Already on maximum tolerated dose of ACE inhibitor or ARB 2, 1
• Baseline serum potassium ≤4.8 mmol/L 2, 1

Absolute contraindications include:

• eGFR <25 mL/min/1.73 m² or end-stage renal disease (ESRD) 2
• Patients on dialysis 2
• Baseline potassium >4.8 mmol/L 2

The landmark FIDELIO-DKD and FIGARO-DKD trials specifically excluded patients with eGFR <25 mL/min/1.73 m², so there is no safety or efficacy data for this population 2. This is a critical pitfall to avoid—do not use finerenone in advanced CKD approaching dialysis.

Treatment Sequencing Algorithm

Follow this stepwise approach:

1. First-line: Maximize RAS inhibitor (ACE inhibitor or ARB) dose 2
2. Second-line: Add SGLT2 inhibitor (prioritize over finerenone due to larger cardiovascular and kidney outcome benefits) 2
3. Third-line: Add finerenone if persistent albuminuria despite SGLT2 inhibitor, or if SGLT2 inhibitor is not tolerated 2

Finerenone can be used in combination with SGLT2 inhibitors with potentially additive benefits 1. The American Journal of Kidney Diseases emphasizes that SGLT2 inhibitors should be prioritized as the next step after RAS inhibition, with finerenone reserved for patients with persistent albuminuria or SGLT2 inhibitor intolerance 2.

Dosing Protocol

Initial dose determination based on eGFR:

• eGFR 25-60 mL/min/1.73 m²: Start 10 mg once daily 2, 1
• eGFR >60 mL/min/1.73 m²: Start 20 mg once daily 2, 1

Dose uptitration after 1 month:

• If serum potassium remains ≤4.8 mmol/L and eGFR is stable, uptitrate from 10 mg to 20 mg daily 2

Potassium Monitoring Strategy

Critical monitoring timepoints:

• Before initiation: Verify potassium ≤4.8 mmol/L 2, 1
• At 4 weeks: Check potassium after initiation and after any dose increase 1
• Ongoing: Regular monitoring throughout treatment 2, 1

Management of hyperkalemia:

• Potassium ≤5.5 mmol/L: Continue finerenone 2
• Potassium >5.5 mmol/L: Withhold finerenone 2
• Restart criteria: When potassium returns to ≤5.0 mmol/L, restart at 10 mg daily 2

Hyperkalemia occurred in 10.8% of finerenone patients versus 5.3% with placebo in trials, but discontinuation rates remained low at only 1.2-2.3% 1, 3. This is substantially lower than with steroidal MRAs due to finerenone's unique tissue distribution and selectivity 4.

Clinical Benefits

Cardiovascular outcomes:

• 14% reduction in composite cardiovascular death, nonfatal MI, nonfatal stroke, and heart failure hospitalization (HR 0.86,95% CI 0.78-0.95) 1
• 29% reduction in heart failure hospitalization (HR 0.71,95% CI 0.56-0.90) 1, 3
• 18% reduction in cardiovascular death or first heart failure hospitalization 5

Kidney outcomes:

• 36% reduction in progression to end-stage kidney disease (HR 0.64,95% CI 0.41-0.995) 1, 3

These benefits apply across the broad spectrum of patients with baseline comorbidities, including those with existing heart failure history or atherosclerotic cardiovascular disease 6. Importantly, the effect on reducing new-onset heart failure (32% reduction) and other heart failure outcomes was consistent regardless of baseline heart failure history 5.

Heart Failure Considerations

Finerenone is particularly valuable for heart failure prevention and treatment in this population 7. The reduction in heart failure hospitalizations was the primary driver of cardiovascular benefit in both major trials 3, 7. Recent FINEARTS-HF trial results show efficacy in HFmrEF and HFpEF populations, expanding finerenone's role beyond CKD-diabetes 7.

Common pitfall: The guidelines state finerenone should not be initiated in patients with "heart failure with reduced ejection fraction" 2, but this appears to reference symptomatic HFrEF that was excluded from the original trials. The evidence clearly supports use in patients with heart failure history, as outcomes were consistent regardless of baseline HF status 5.