Is finerenone used in non-proteinuric Chronic Kidney Disease (CKD)?

From the Guidelines

Finerenone is not currently recommended for use in nonproteinuric chronic kidney disease (CKD). Finerenone (brand name Kerendia) is a nonsteroidal mineralocorticoid receptor antagonist that has been specifically approved for patients with CKD associated with type 2 diabetes who have albuminuria (protein in the urine) 1. The drug's approval was based on clinical trials (FIDELIO-DKD and FIGARO-DKD) that specifically enrolled patients with diabetic kidney disease who had albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) 1. The presence of albuminuria was a key inclusion criterion for these studies, as the drug works by blocking mineralocorticoid receptors, which helps reduce inflammation and fibrosis that contribute to kidney damage in proteinuric conditions.

Some key points to consider when evaluating the use of finerenone in nonproteinuric CKD include:

• The lack of evidence from clinical trials in nonproteinuric CKD patients, which makes it difficult to determine the benefits and safety profile of finerenone in this population 1.
• The potential risks associated with finerenone, such as hyperkalemia, which may be more pronounced in patients with nonproteinuric CKD 1.
• The importance of other treatment approaches, such as blood pressure control, glycemic management (if diabetic), and lifestyle modifications, which remain the standard of care for patients with nonproteinuric CKD 1.

Overall, while finerenone has shown promise in reducing cardiovascular and renal outcomes in patients with proteinuric CKD, its use in nonproteinuric CKD is not currently recommended due to the lack of evidence and potential risks. Other treatment approaches should be prioritized for patients with nonproteinuric CKD.

From the Research

Use of Finerenone in Non-Proteinuric CKD

• Finerenone is a non-steroidal mineralocorticoid receptor antagonist that has been studied for its potential benefits in patients with chronic kidney disease (CKD) 2, 3, 4, 5, 6.
• The FIND-CKD study is a randomized, double-blind, placebo-controlled phase 3 trial that investigates the effect of finerenone in adults with CKD without diabetes 2.
• The study includes patients with a urinary albumin:creatinine ratio (UACR) ≥200-≤3500 mg/g and an estimated glomerular filtration rate (eGFR) ≥25-<90 ml/min/1.73 m2 2.
• Finerenone has been shown to reduce the risk of kidney and cardiovascular events in patients with CKD and type 2 diabetes 3, 4, 5.
• The FIDELITY analysis, a prespecified pooled analysis of the FIDELIO-DKD and FIGARO-DKD studies, found that finerenone reduced the risk of cardiovascular and kidney outcomes in patients with CKD and type 2 diabetes 4.
• Finerenone has also been shown to be effective in reducing the risk of kidney and cardiovascular events in patients with CKD and type 2 diabetes who are taking sodium-glucose cotransporter 2 inhibitors (SGLT2is) 5.
• The use of finerenone in non-proteinuric CKD is not directly addressed in the available studies, but its benefits in reducing the risk of kidney and cardiovascular events in patients with CKD and type 2 diabetes suggest that it may be a useful treatment option for patients with non-proteinuric CKD 2, 3, 4, 5, 6.

Mechanism of Action and Safety

• Finerenone works by antagonizing the mineralocorticoid receptor, which plays a key role in the regulation of blood pressure and electrolyte balance 6.
• Finerenone has been shown to have a potent and selective anti-fibrotic and anti-proteinuric effect, and is associated with a lower incidence of adverse effects compared to steroid mineralocorticoid receptor antagonists 6.
• The safety of finerenone has been evaluated in several studies, and it has been found to be generally well-tolerated, with a similar incidence of adverse events compared to placebo 3, 4, 5.
• However, finerenone has been associated with an increased risk of hyperkalemia, particularly in patients with advanced CKD or those taking other medications that increase potassium levels 3, 4, 5.