In an adult with chronic kidney disease and type 2 diabetes mellitus, albuminuria, estimated glomerular filtration rate 45 mL/min/1.73 m², serum potassium 4.8 mmol/L, already on a maximally tolerated angiotensin‑converting enzyme inhibitor or angiotensin receptor blocker and a sodium‑glucose co‑transporter‑2 inhibitor, how should I initiate Kerendia (finerenone) regarding starting dose, titration, and monitoring?

Initiating Kerendia (Finerenone) in Diabetic CKD with Albuminuria

Start finerenone 10 mg once daily in this patient with eGFR 45 mL/min/1.73 m² and potassium 4.8 mmol/L, check potassium at 1 month, and uptitrate to 20 mg daily if potassium remains ≤4.8 mmol/L. 1, 2

Patient Eligibility Confirmation

Your patient meets all criteria for finerenone initiation:

• eGFR 45 mL/min/1.73 m² falls within the approved range (≥25 mL/min/1.73 m²) 1, 2
• Serum potassium 4.8 mmol/L meets the mandatory threshold (≤4.8 mmol/L) 1, 2
• Albuminuria present with maximally tolerated ACEi/ARB already on board 1, 2
• SGLT2 inhibitor already prescribed, satisfying the treatment hierarchy 1, 2

Starting Dose Algorithm

The eGFR-based dosing protocol is straightforward:

• 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

Your patient's eGFR of 45 requires the 10 mg starting dose. 1, 2

Titration Protocol

After exactly 1 month of treatment, increase from 10 mg to 20 mg daily if ALL of the following are met:

• Serum potassium remains ≤4.8 mmol/L 1, 2
• eGFR is stable (no clinically significant decline) 2, 3
• No hyperkalemia-related symptoms or adverse effects 1, 2

The 1-month interval captures the predictable early potassium rise associated with mineralocorticoid receptor antagonism. 2, 3

Potassium Monitoring Schedule

Follow this exact monitoring protocol:

Timepoint	Action
Pre-initiation	Confirm potassium ≤4.8 mmol/L (already done: 4.8 mmol/L) [1,2]
1 month	Check potassium to guide dose titration [1,2]
Every 4 months	Ongoing potassium monitoring during maintenance [1,2]

Potassium-Based Management Algorithm

Use this decision tree at each monitoring point:

Potassium Level	Action
≤4.8 mmol/L	Continue current dose; proceed with uptitration at month 1 if on 10 mg [1,2]
4.9–5.5 mmol/L	Continue current dose without adjustment; maintain monitoring every 4 months [1,2]
>5.5 mmol/L	Hold finerenone immediately; adjust dietary potassium, review concomitant medications (NSAIDs, potassium-sparing diuretics), recheck potassium; restart at 10 mg daily once potassium ≤5.0 mmol/L [1,2]

Additional Monitoring Parameters

Beyond potassium, track these parameters:

• eGFR: Baseline, 1 month, then every 4 months 2, 3
• UACR (albuminuria): Baseline and month 4 to assess therapeutic response 2, 3

Do not discontinue finerenone for an early eGFR decline up to 30% from baseline—this reflects beneficial hemodynamic reduction of intraglomerular pressure, not acute kidney injury. 3

Expected Clinical Benefits

This patient can anticipate substantial cardiorenal protection:

• 23% reduction in composite kidney outcome (kidney failure, sustained eGFR decline ≥57%, renal death) 2, 4
• 36% reduction in progression to end-stage kidney disease 2, 5, 6
• 14% reduction in major cardiovascular events (CV death, nonfatal MI, nonfatal stroke, heart failure hospitalization) 2, 5, 6
• 29% reduction in heart failure hospitalization 5, 6

These outcomes derive from the FIDELIO-DKD and FIGARO-DKD trials and the pooled FIDELITY analysis. 2, 4, 6

Common Pitfalls to Avoid

Do not make these errors:

• Do not permanently discontinue finerenone 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
• Do not skip the 1-month potassium check before uptitration—this is when the predictable potassium rise occurs 1, 2
• Do not misinterpret an early modest eGFR decline as pathological AKI; creatinine increases up to 30% reflect hemodynamic benefit, not tubular injury 3
• Do not underdose out of fear; the trials used maximally tolerated doses (10–20 mg) to achieve the documented benefits 2, 3

Safety Profile

Hyperkalemia is the primary safety concern:

• Hyperkalemia (K⁺ >5.5 mmol/L) occurred in 14% of finerenone patients versus 6.9% with placebo 2, 5
• Permanent discontinuation due to hyperkalemia was rare: 1.7% versus 0.6% with placebo 2, 5
• No deaths attributed to hyperkalemia over 3 years of follow-up 2, 5

Protective factors that reduce hyperkalemia risk:

• Concomitant SGLT2 inhibitor use (your patient is already on one) 3
• Concomitant diuretic therapy 3

Risk factors for hyperkalemia:

• Lower eGFR, especially <45 mL/min/1.73 m² (your patient is at this threshold) 3
• Beta-blocker use 3

Treatment Hierarchy Context

KDIGO 2024 recommends this sequence for diabetic CKD with albuminuria:

1. First-line foundation: Maximally tolerated ACEi or ARB (already done) 1, 2
2. Second-line priority: SGLT2 inhibitor (already done) 1, 2
3. Third-line consideration: Finerenone for persistent albuminuria despite above therapies (your patient's current situation) 1, 2

Your patient is appropriately positioned for finerenone initiation, having completed steps 1 and 2. 1, 2