Finerenone in Glomerulonephritis
Finerenone is NOT indicated for primary glomerulonephritis and should not be used in this population. The evidence base for finerenone is exclusively in diabetic kidney disease (DKD), not primary glomerular diseases.
Evidence Base Limitation
The landmark trials establishing finerenone's efficacy—FIDELIO-DKD and FIGARO-DKD—specifically enrolled patients with type 2 diabetes and chronic kidney disease with albuminuria, not primary glomerulonephritis 1. These trials demonstrated cardiovascular and renal benefits only in the diabetic CKD population, with hazard ratios of 0.86 for cardiovascular outcomes and 0.77 for kidney disease progression 1.
Approved Indication
Finerenone is FDA-approved exclusively for patients with type 2 diabetes and CKD with albuminuria 1, 2. The specific criteria for use include:
- Type 2 diabetes with persistent albuminuria (UACR ≥30 mg/g) 1, 2
- eGFR 25-90 mL/min/1.73 m² 1, 2, 3
- Already on maximum tolerated dose of ACE inhibitor or ARB 1
- Serum potassium ≤4.8 mmol/L 1, 2, 4
Why Not for Primary Glomerulonephritis
Primary glomerular diseases (IgA nephropathy, focal segmental glomerulosclerosis, membranous nephropathy, minimal change disease, etc.) have fundamentally different pathophysiology than diabetic kidney disease. The mineralocorticoid receptor antagonism that benefits diabetic nephropathy has not been studied or validated in non-diabetic glomerular diseases 1.
The mechanism of benefit in DKD relates to:
- Reduction of inflammation and fibrosis specific to diabetic kidney injury 1
- Cardiovascular protection in the context of diabetes-related metabolic dysfunction 1, 3
- Albuminuria reduction in diabetic nephropathy specifically 5, 6
Treatment Approach for Glomerulonephritis
For patients with primary glomerulonephritis, the appropriate management depends on the specific diagnosis:
Standard therapy includes:
- RAS inhibition (ACE inhibitor or ARB) for proteinuria reduction 1
- SGLT2 inhibitors (which DO have evidence in non-diabetic CKD, including glomerulonephritis) 1
- Immunosuppression when indicated based on specific glomerular disease type 1
- Blood pressure control targeting <120 mmHg systolic in most cases 1
Critical Caveat
If a patient has BOTH type 2 diabetes AND biopsy-proven glomerulonephritis, finerenone could theoretically be considered, but only if they meet all the diabetic CKD criteria above 1. However, this scenario would require careful nephrology consultation, as the evidence base did not specifically study this dual-diagnosis population 1, 2.
Safety Concerns in Glomerulonephritis
Even if considered off-label, finerenone carries significant hyperkalemia risk (14% vs 6.9% with placebo), with 1.7% discontinuation rates 1. In glomerulonephritis patients who may already be on RAS inhibitors and potentially immunosuppression, this risk would be amplified without proven benefit 4.