In a non‑diabetic chronic kidney disease patient with a urine albumin‑to‑creatinine ratio of approximately 25,700 mg/g who is already on an ACE inhibitor or angiotensin receptor blocker, should finerenone be added, and what are the recommended dosing and monitoring parameters?

Finerenone in Non-Diabetic CKD with Severe Albuminuria

Finerenone should be considered for this non-diabetic CKD patient with severe albuminuria (UACR 25,700 mg/g) on maximal RAS inhibitor therapy, as emerging real-world evidence demonstrates significant albuminuria reduction and safety in non-diabetic populations, though this represents off-label use since current guidelines specifically address only type 2 diabetes. 1, 2

Critical Context: Off-Label Use

The 2024 KDIGO guidelines explicitly recommend finerenone only for adults with type 2 diabetes and CKD with eGFR >25 mL/min/1.73 m², normal potassium, and albuminuria >30 mg/g despite maximum tolerated RAS inhibitor. 1 This patient does not meet the diabetes criterion, making this off-label use.

However, recent real-world evidence supports efficacy in non-diabetic CKD:

• A 2025 single-center study of 37 non-diabetic CKD patients showed median UACR reduction of 664.95 mg/g with stable eGFR and no hyperkalemia-related discontinuations. 2
• A 2024 randomized trial in non-diabetic CKD (eGFR 25-45 mL/min/1.73 m²) demonstrated 24% UACR reduction with finerenone monotherapy and 34% reduction when combined with dapagliflozin. 3

Treatment Algorithm for This Patient

Step 1: Optimize Foundation Therapy First

• Verify maximal tolerated RAS inhibitor dose (ACE inhibitor or ARB) is achieved. 1
• Add SGLT2 inhibitor as priority before finerenone, as KDIGO 2024 recommends SGLT2i for non-diabetic CKD with UACR ≥200 mg/g (this patient has 25,700 mg/g). 1
• SGLT2i provides larger effects on kidney and cardiovascular outcomes and reduces hyperkalemia risk when combined with finerenone. 3, 4

Step 2: Pre-Initiation Requirements for Finerenone

Verify all criteria before starting:

• eGFR ≥25 mL/min/1.73 m² 1, 5
• Serum potassium ≤4.8 mmol/L 1, 5
• Patient on maximum tolerated RAS inhibitor 1
• Persistent severe albuminuria despite above therapies 1

Do not initiate if:

• eGFR <25 mL/min/1.73 m² (no safety data) 5
• Baseline potassium >4.8 mmol/L 1, 5
• End-stage renal disease or dialysis 5

Step 3: Dosing Protocol

Initial dose based on eGFR: 1, 5

• eGFR 25-59 mL/min/1.73 m²: Start finerenone 10 mg once daily
• eGFR ≥60 mL/min/1.73 m²: Start finerenone 20 mg once daily

Dose titration at 1 month: 1, 5

• Increase from 10 mg to 20 mg daily only if:
  • Serum potassium remains ≤4.8 mmol/L
  • eGFR stable (no significant decline)
  • Medication well-tolerated

Step 4: Monitoring Parameters

Potassium monitoring schedule: 1, 5

• Pre-initiation: Confirm K+ ≤4.8 mmol/L
• 1 month: Check K+ and eGFR
• Every 4 months thereafter: Check K+ and eGFR

Potassium-based management algorithm: 1

Potassium Level	Action
≤4.8 mmol/L	Continue current dose; monitor every 4 months [1]
4.9-5.5 mmol/L	Continue current dose; maintain monitoring every 4 months [1]
>5.5 mmol/L	Hold finerenone immediately; adjust dietary potassium; review concomitant medications; recheck K+; restart at 10 mg daily when K+ ≤5.0 mmol/L [1]

Additional monitoring:

• UACR at baseline and month 4 to assess response 5
• eGFR at baseline, 1 month, then every 4 months 5

Expected Benefits in Non-Diabetic CKD

Based on the limited but emerging evidence:

• Albuminuria reduction: 24-34% reduction in UACR when added to RAS inhibitor, with additive effects when combined with SGLT2i. 3, 2
• eGFR stability: No significant eGFR decline observed in non-diabetic populations over 6-12 months. 3, 2
• Safety profile: Hyperkalemia rates similar to diabetic populations, with no treatment discontinuations in real-world cohorts. 2

Critical Safety Considerations

Hyperkalemia risk factors in this patient: 5, 6

• Lower eGFR (<45 mL/min/1.73 m²) increases risk
• Concomitant beta-blocker use increases risk
• SGLT2i co-administration reduces risk (protective)

Management of acute eGFR decline: 6

• <30% decline from baseline: Continue both medications with close monitoring
• 30-40% decline: Temporarily suspend finerenone; maintain RAS inhibitor; investigate reversible causes (volume depletion, NSAIDs, contrast); restart at 10 mg when stable
• >40% decline or eGFR <25 mL/min/1.73 m²: Permanently discontinue finerenone; urgent nephrology referral

Common Pitfalls to Avoid

1. Do not discontinue prematurely for single hyperkalemia episode >5.5 mmol/L. Temporary interruption with dose reduction (10 mg) upon restart manages most cases successfully. 1, 6

2. Do not interpret initial hemodynamic eGFR decrease as pathological AKI. A reversible eGFR decline in the first months is expected and not an indication to stop therapy. 6

3. Do not use finerenone as monotherapy. It should only be added after maximizing RAS inhibitor and SGLT2i therapy. 1

4. Do not ignore volume status. Volume depletion is a common, reversible cause of AKI in patients on triple therapy (RAS inhibitor + SGLT2i + finerenone). 6

Strength of Evidence Considerations

Important limitation: The patient lacks diabetes, which is the only FDA-approved and guideline-supported indication for finerenone. 1 The evidence in non-diabetic CKD consists of:

• One small real-world study (n=37) 2
• One small randomized trial (n=20) 3

However, the mechanistic rationale is strong: Mineralocorticoid receptor overactivation drives kidney fibrosis and albuminuria independent of diabetes status. 3, 2 The severe albuminuria (UACR 25,700 mg/g) indicates high risk for CKD progression, justifying consideration of all evidence-based therapies even if off-label.

Practical Implementation

Shared decision-making discussion should include:

• Off-label use with limited but promising evidence in non-diabetic CKD
• Potential for substantial albuminuria reduction (20-35% based on available data)
• Hyperkalemia risk requiring structured monitoring
• Need for SGLT2i optimization first
• Alternative of nephrology referral for specialized management given severe albuminuria

If proceeding, document:

• Rationale for off-label use
• Discussion of risks/benefits
• Patient understanding and consent
• Plan for structured monitoring