Management of Acute Kidney Injury Associated with Finerenone and ARA2

Introduction to Management Strategies

The American Journal of Kidney Diseases recommends not suspending finerenone or ARA2 abruptly in the event of an acute increase in creatinine, but rather evaluating the underlying cause of acute kidney injury, managing reversible factors, and considering temporary dose reduction before permanent discontinuation 1, 2

The American Journal of Kidney Diseases suggests evaluating serum potassium immediately, as hyperkalemia is a primary safety concern with the combination of finerenone and ARA2, and seeking precipitating factors such as dehydration, NSAID use, contrast media, infections, or concomitant use of other potassium-increasing medications 1, 5
Diabetes Care recommends monitoring potassium and creatinine weekly until stabilization if potassium levels are ≤5.0 mmol/L 3, 7

If potassium levels are 5.1-5.5 mmol/L, temporarily suspend finerenone (not ARA2), implement measures to reduce potassium, and consider restarting finerenone at 10 mg daily when potassium levels are ≤5.0 mmol/L 1, 2, 6
If potassium levels are >5.5 mmol/L, immediately suspend finerenone, consider reducing the dose of ARA2 by half temporarily, and actively treat hyperkalemia according to standard protocols 1, 2, 3, 5, 7

If eGFR decreases by <30% from baseline, continue both medications with close monitoring, ensuring no volume depletion or nephrotoxic use 1, 2, 5
If eGFR decreases by 30-40% from baseline, temporarily suspend finerenone, maintain ARA2 unless contraindicated, investigate reversible causes of acute kidney injury, and consider restarting finerenone at a reduced dose (10 mg) when eGFR stabilizes 1, 2, 3, 4, 5, 6
If eGFR decreases by >40% from baseline or falls <25 mL/min/1.73 m², permanently suspend finerenone, evaluate if ARA2 should be continued based on individual clinical context, and refer to nephrology urgently 1, 2, 3, 5, 6, 7

Consider adding an SGLT2 inhibitor if not already in use, as it may allow continuation of both medications with lower risk of hyperkalemia due to its kaliuretic effect 2, 7
Ensure ARA2 is at the maximum tolerated dose before initiating finerenone, and monitor potassium and creatinine structuredly 2, 3, 6, 7

Avoid premature suspension of disease-modifying therapy, as it is associated with worse clinical outcomes; instead, prioritize identifying and correcting reversible causes first 1
Recognize the expected hemodynamic decrease in eGFR during the initial months of treatment and do not interpret it as pathological acute kidney injury 1
Always evaluate the volume status, as volume depletion is a common and reversible cause of acute kidney injury in this context 1, 5

Refer to nephrology if eGFR is <30 mL/min/1.73 m² for discussion of renal replacement therapy, if there is recurrent hyperkalemia despite optimal management, uncertainty about the etiology of kidney disease, or a continuous decline in eGFR or increase in albuminuria despite optimal therapy 1, 2, 3, 7
Finerenone reduces the risk of progression of chronic kidney disease by 23% and end-stage renal disease by 36%, despite initial acute declines in eGFR, and its use is justified by cardiovascular benefits (reduction of 14% in composite cardiovascular events) when it is safe to continue therapy 6, 7