How does finerenone fare among DKD patients in real life?

In patients with chronic kidney disease and type 2 diabetes who have not been previously treated with any mineralocorticoid receptor antagonist (MRA), the use of finerenone results in marked reductions in albuminuria, reports a study presented at ERA 2025.

However, treatment with finerenone has led to an increased incidence of hyperkalemia, according to lead study author Dr Sara Aladro, Hospital Universitario Insular materno-infantil, Servicio de Nefrología, Las Palmas de Gran Canaria, Spain.

“Due to high prevalence of diabetic kidney disease (DKD), understanding the real-world impact of finerenone is essential,” Aladro said. “We observed a significant decrease in albuminuria in patients without previous MRA, but higher incidence of hyperkalemia.”

Sixty-six patients (mean age 68.2 years, 22.7 percent female) with DKD participated in this descriptive, observational, prospective study. Participants initiated treatment with finerenone between May 2024 and January 2025.

Aladro and her team analysed the demographic data, clinical characteristics, laboratory parameters, echocardiographic findings, and treatment history of DKD patients. In addition, they performed a subanalysis to examine the impact of the study drug in participants with at least 4 months of follow-up.

Older patients with a higher percentage of heart failure (HR; 42.4 percent) were included in the analysis. Of these, 16.7 percent had reduced left ventricular ejection fraction (LVEF <40 percent), 7.6 percent had mid-range ejection fraction (LVEF 41‒49 percent), and 18.2 percent had preserved ejection fraction (LVEF ≥50 percent). Additionally, two patients were kidney transplant recipients. [ERA 2025, abstract 3569]

Baseline characteristics

Based on baseline analytical data, the present cohort had a lower estimated glomerular filtration rate (eGFR; 57.5 vs 47.5 ml/min/1.73 m²; p<0.001) and higher serum potassium levels (4.35 vs 4.54 mEq/L; p<0.001) than those in the pooled FIDELITY study. No significant difference was seen in albumin-to-creatinine ratio (UACR; 514 vs 522 mg/g). The median 24-h proteinuria level was 1.28 g/24h.

“Despite the small sample size, our registry includes older patients with lower eGFR and similar levels of UACR,” Aladro said.

The majority of these patients (87.9 percent) initiated finerenone at a dose of 10 mg, while the remaining participants (12.1 percent) started at 20 mg.

In terms of baseline treatment, the present cohort had a higher use of GLP-1 receptor agonists (7.6 percent vs 28.8 percent), SGLT2 inhibitors (6.7 percent vs 92.4 percent), and potassium binders (1.4 percent vs 4.6 percent) than those in FIDELITY. On the other hand, the use of RAAS inhibitors did not significantly differ between the two groups (99.8 percent vs 86.4 percent).

Nearly half of the participants in this study (n=1, 46.9 percent) had at least 4 months of follow-up. Finerenone could be titrated in seven patients (22.6 percent).

Laboratory findings

UACR significantly decreased in DKD patients who received finerenone, particularly in those without previous use of any MRA. There was also no significant worsening of renal function observed (38 vs 36.5 ml/min/1.73 m²; p=0.103). However, 12 patients (36.4 percent) experienced a mild case of hyperkalemia, but this had no significant clinical impact.

Treatment discontinuation did not occur, and no adverse events were reported. One patient with HF was hospitalized, and another died from a noncardiovascular cause during follow-up.

“Longer follow-up and larger patient recruitment are needed to further assess the efficacy and safety of finerenone in [the] real world,” according to Aladro.

“Finerenone is a novel nonsteroidal MRA that has been shown to improve renal outcomes in patients with DKD, as demonstrated in FIGARO and FIDELIO-DKD trials,” she said.