Is Kerendia (finerenone) recommended for a patient with impaired renal function, significant proteinuria, and a left ventricular ejection fraction of 60-65%?

Kerendia (Finerenone) is Strongly Recommended for This Patient

Yes, finerenone is indicated and should be initiated in this patient with type 2 diabetes, eGFR 51 mL/min/1.73 m², albumin-to-creatinine ratio 685 mg/g, and preserved ejection fraction (60-65%). This patient meets all the key criteria established by major guidelines and landmark trials.

Patient Eligibility Confirmation

This patient satisfies all critical inclusion criteria for finerenone therapy:

• eGFR 51 mL/min/1.73 m² falls within the approved range of 25-90 mL/min/1.73 m², specifically meeting the FIDELIO-DKD and FIGARO-DKD trial enrollment criteria 1, 2
• Albumin-to-creatinine ratio of 685 mg/g represents significant albuminuria (>30 mg/g threshold), indicating high risk for both CKD progression and cardiovascular events 1, 3
• Preserved ejection fraction (60-65%) is appropriate for finerenone, as the FIGARO-DKD trial specifically enrolled patients without heart failure with reduced ejection fraction, making the evidence strongest for HFpEF and preserved EF 3

Dosing Algorithm for This Patient

Start finerenone 10 mg once daily based on the eGFR of 51 mL/min/1.73 m² 1, 3:

• For eGFR 25-60 mL/min/1.73 m², the recommended starting dose is 10 mg daily 1, 3
• Verify serum potassium ≤4.8 mmol/L before initiating therapy 1, 3
• After 1 month, if serum potassium remains ≤4.8 mmol/L and the medication is well-tolerated, uptitrate to 20 mg daily 1

Required Pre-Treatment Optimization

Before starting finerenone, confirm the patient is on maximum tolerated RAS inhibitor therapy:

• Finerenone should only be added to patients already on maximum tolerated dose of ACE inhibitor or ARB 1, 2
• The KDIGO 2022 guidelines recommend the treatment sequence: (1) RAS inhibitor at maximum tolerated dose, (2) SGLT2 inhibitor as second-line priority, (3) finerenone for persistent albuminuria despite SGLT2 inhibitor or SGLT2i intolerance 1, 3
• If this patient is not yet on an SGLT2 inhibitor, strongly consider adding one first, as SGLT2 inhibitors have larger effects on reducing kidney and cardiovascular outcomes 1

Expected Clinical Benefits for This Patient

The evidence supporting finerenone in this clinical scenario is robust:

• 18% reduction in composite kidney outcomes (kidney failure, sustained ≥40% eGFR decrease, or kidney death) with HR 0.82 1, 2
• 36% reduction in progression to end-stage kidney disease with HR 0.64 4, 2
• 13-14% reduction in cardiovascular events (cardiovascular death, MI, stroke, heart failure hospitalization) with HR 0.86-0.87 3, 2
• 29% reduction in heart failure hospitalizations specifically, which is particularly relevant given the preserved ejection fraction 3, 2
• Significant albuminuria reduction, with 53.2% of patients achieving ≥30% reduction in UACR, which mediated 84% of the treatment effect on kidney outcomes 5, 6

Potassium Monitoring Protocol

Hyperkalemia is the primary safety concern, requiring systematic monitoring:

• Baseline potassium must be ≤4.8 mmol/L before starting finerenone 1, 3
• Check potassium at 1 month after initiation to capture the predictable initial rise 1
• Monitor potassium every 4 months during maintenance therapy 1
• Management thresholds: Continue if potassium ≤5.5 mmol/L; hold if >5.5 mmol/L and restart at 10 mg daily when potassium returns to ≤5.0 mmol/L 1, 3

Safety Profile and Risk Mitigation

The safety data from the landmark trials is reassuring:

• Hyperkalemia occurred in 10.8% vs 5.3% with placebo, but permanent discontinuation due to hyperkalemia was only 1.7% vs 0.6% over 3 years 1, 2
• No deaths attributed to hyperkalemia in either FIDELIO-DKD or FIGARO-DKD trials 2
• The risk is significantly lower than with steroidal MRAs like spironolactone, and finerenone does not cause gynecomastia 7, 8

Common Pitfalls to Avoid

• Do not initiate finerenone without first optimizing RAS inhibitor therapy to maximum tolerated dose 1
• Do not permanently discontinue for a single potassium >5.5 mmol/L episode—temporary interruption with dose reduction upon restart successfully manages most cases 1
• Do not delay initiation in patients with preserved EF—the evidence is strongest for this population, as HFrEF patients were excluded from FIGARO-DKD 3
• Consider SGLT2 inhibitor first if not already prescribed, as guidelines prioritize SGLT2i over finerenone as second-line therapy after RAS inhibition 1

Guideline Support

Multiple major guidelines support this recommendation:

• KDIGO 2022 guidelines recommend finerenone (Grade 2A) for patients with type 2 diabetes, eGFR >25 mL/min/1.73 m², albuminuria (UACR >30 mg/g), normal serum potassium, and already on maximum tolerated RAS inhibitor 2
• American Diabetes Association 2024 recommends finerenone for patients with type 2 diabetes and CKD, eGFR ≥20 mL/min/1.73 m², UACR ≥30 mg/g despite standard therapy 3, 2
• American College of Cardiology recommends considering finerenone for patients with type 2 diabetes with CKD (eGFR 25-90 mL/min/1.73 m²) and albuminuria (UACR ≥30 mg/g) who are already on maximum tolerated RAS inhibitor 3