What is the recommended starting dose of Kerendia (finerenone) for adults with chronic kidney disease and type 2 diabetes, and how should the dose be adjusted based on estimated glomerular filtration rate and serum potassium levels?

Kerendia (Finerenone) Dosing

Start finerenone at 10 mg once daily if eGFR is 25–59 mL/min/1.73 m², or 20 mg once daily if eGFR is ≥60 mL/min/1.73 m², provided serum potassium is ≤4.8 mmol/L. 1

Patient Eligibility Criteria

Before initiating finerenone, confirm the following:

• Type 2 diabetes with CKD and persistent albuminuria (UACR ≥30 mg/g) despite maximum tolerated ACE inhibitor or ARB therapy 1, 2
• eGFR ≥25 mL/min/1.73 m² (do not initiate below this threshold) 1, 3
• Serum potassium ≤4.8 mmol/L at baseline 1, 2
• Patient must already be on maximally tolerated RAS inhibitor (ACE-I or ARB) 1, 2, 3

Initial Dosing Algorithm

The starting dose is determined solely by eGFR:

• eGFR 25–59 mL/min/1.73 m² → Start 10 mg once daily 1, 2
• eGFR ≥60 mL/min/1.73 m² → Start 20 mg once daily 1, 2

Real-world data confirm that 81% of patients initiate at 10 mg, reflecting the typical CKD population with reduced eGFR. 4

Dose Titration After 1 Month

Increase from 10 mg to 20 mg daily after 1 month if all three conditions are met: 1, 2

1. Serum potassium remains ≤4.8 mmol/L
2. eGFR is stable (no clinically significant decline)
3. Medication is well tolerated

In real-world practice, approximately 26% of patients starting at 10 mg successfully uptitrate to 20 mg. 4

Potassium-Based Dose Adjustments

Monitor serum potassium at 1 month after initiation, then every 4 months during maintenance therapy. 1, 2

Serum Potassium (mmol/L)	Action
≤4.8	Continue current dose (10 or 20 mg); monitor every 4 months [1]
4.9–5.5	Continue current dose without adjustment; maintain monitoring every 4 months [1]
>5.5	Hold finerenone immediately; adjust dietary potassium and review concomitant medications; recheck potassium; restart at 10 mg daily once potassium ≤5.0 mmol/L [1,2]

Treatment Sequencing in Diabetic CKD

Finerenone should be added as third-line therapy after optimizing foundation treatments: 2, 3

1. First-line: Maximum tolerated ACE inhibitor or ARB
2. Second-line: SGLT2 inhibitor (provides largest renal and cardiovascular benefit)
3. Third-line: Finerenone for persistent albuminuria despite above, or if SGLT2i is contraindicated/not tolerated

KDIGO 2024 emphasizes that SGLT2 inhibitors should be prioritized before finerenone because they reduce hyperkalemia risk when combined with finerenone and deliver superior outcomes. 1, 2

Monitoring Schedule

• Serum potassium: Pre-initiation (must be ≤4.8 mmol/L), at 1 month, then every 4 months 1, 2
• eGFR: Baseline, 1 month, then every 4 months 2, 3
• UACR: Baseline and at month 4 to assess albuminuria response 2, 3

Safety Profile and Hyperkalemia Management

Hyperkalemia (potassium >5.5 mmol/L) occurred in 21.4% of finerenone patients vs 9.2% with placebo over 2.6 years in FIDELIO-DKD, but permanent discontinuation due to hyperkalemia was rare (1.7% vs 0.6%). 5, 6 In real-world practice, hyperkalemia led to discontinuation in only 1% of patients and hospitalization in 0.3%. 4

Risk factors for hyperkalemia include: 5

• Lower eGFR (especially <45 mL/min/1.73 m²)
• Higher baseline potassium
• Female sex
• Beta-blocker use

Protective factors include: 5

• SGLT2 inhibitor co-administration
• Diuretic use

Common Pitfalls to Avoid

• Do not discontinue finerenone permanently after a single potassium reading >5.5 mmol/L; temporarily hold, correct potassium, and restart at 10 mg once potassium ≤5.0 mmol/L 1, 2, 3
• Do not use finerenone as monotherapy; it must be added only after maximally tolerated ACE/ARB (and SGLT2i when indicated) 1, 2, 3
• Do not initiate if eGFR <25 mL/min/1.73 m²; no established dosing or safety data exist for this population 3, 7
• Do not misinterpret early modest eGFR decline as pathological; a reversible hemodynamic change is expected in the first months 2, 3

Contraindications

Absolute contraindications: 2, 3

• eGFR <25 mL/min/1.73 m² or end-stage renal disease
• Baseline serum potassium >4.8 mmol/L
• Not on maximum tolerated RAS inhibitor

Expected Clinical Benefits

Finerenone provides significant cardiorenal protection: 2, 3, 6

• 36% reduction in progression to end-stage kidney disease (HR 0.64,95% CI 0.41–0.995)
• 18% reduction in composite kidney outcomes (kidney failure, sustained ≥40% eGFR decline, or kidney death)
• 14% reduction in composite cardiovascular outcomes (CV death, nonfatal MI, nonfatal stroke, or HF hospitalization)