Should Finerenone Be Discontinued in a Hypotensive Patient with a Solitary Kidney?
Yes, finerenone should be immediately discontinued in this patient with severe hypotension (BP 75/61 mmHg) and a solitary kidney, as hypotension represents a contraindication to continued therapy and poses significant risk for acute kidney injury in a patient with reduced renal reserve.
Immediate Clinical Action Required
- Discontinue finerenone immediately when systolic blood pressure falls below 90 mmHg or the patient develops symptomatic hypotension, as this represents a serious adverse event requiring drug cessation 1, 2.
- Assess for volume depletion, acute illness, or nephrotoxin exposure (NSAIDs, contrast agents), as these conditions mandate holding finerenone regardless of blood pressure 2.
- Monitor serum creatinine and potassium urgently within 24-48 hours after discontinuation, as the combination of hypotension and a solitary kidney dramatically increases acute kidney injury risk 1, 2.
Why Hypotension Is a Critical Contraindication
- Finerenone significantly increases the risk of hypotension (RR 1.49,95% CI 1.31-1.68) compared to placebo, and this effect is amplified when combined with other blood pressure-lowering agents 3.
- The FIGARO-DKD trial specifically excluded patients with uncontrolled hypertension or hemodynamic instability, meaning there is no safety data for finerenone use in hypotensive patients 1.
- In a patient with a solitary kidney, hypotension-induced renal hypoperfusion carries catastrophic risk because there is no contralateral kidney to compensate for acute ischemic injury 2.
Special Considerations for Solitary Kidney
- A solitary kidney patient has zero renal reserve—any acute insult (hypotension, volume depletion, nephrotoxin) can precipitate dialysis-dependent kidney failure 2.
- While finerenone trials enrolled patients with eGFR ≥25 mL/min/1.73 m², none of these trials specifically studied or reported outcomes in solitary kidney patients, making extrapolation of safety data inappropriate in this high-risk scenario 1, 2.
- The expected hemodynamic creatinine rise of up to 30% with finerenone 2 becomes unacceptable in a solitary kidney when baseline perfusion is already compromised by systemic hypotension.
When Finerenone Can Be Reconsidered
Do not restart finerenone until:
- Systolic blood pressure is consistently ≥110 mmHg and the patient is asymptomatic 1, 2
- The cause of hypotension has been identified and corrected (volume depletion, medication adjustment, acute illness resolution) 2
- Serum creatinine has returned to within 30% of baseline 2
- Serum potassium is ≤5.0 mmol/L 2
If restarting is considered, use the lowest dose (10 mg daily) and monitor blood pressure, creatinine, and potassium at 1 week, 2 weeks, and 1 month 1, 2.
Common Pitfalls to Avoid
- Do not continue finerenone "to preserve cardiorenal benefits" when the patient is hypotensive—the immediate risk of acute kidney injury and cardiovascular collapse far outweighs any long-term benefit 2, 3.
- Do not assume the hypotension is unrelated to finerenone—mineralocorticoid receptor antagonists reduce blood pressure through sodium excretion and vascular effects, and this patient's BP of 75/61 mmHg is dangerously low 1, 3.
- Do not restart finerenone without first optimizing blood pressure control with other agents (dihydropyridine calcium channel blockers, diuretics) that do not carry the same hyperkalemia risk in a solitary kidney 1.
Nephrology Referral Threshold
- Refer urgently to nephrology if serum creatinine rises >30% from baseline after holding finerenone, as this suggests acute kidney injury rather than hemodynamic effect 2.
- Refer for ongoing management when eGFR falls below 30 mL/min/1.73 m² (stage 4 CKD) to discuss renal replacement planning, especially critical in a solitary kidney patient 1, 2.