Chronic Kidney Disease Management

Patient Selection and Dosing

• The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends a dose of 10 mg once daily for patients with an estimated glomerular filtration rate (eGFR) of 25-59 ml/min/1.73 m², and 20 mg once daily for patients with an eGFR of ≥60 ml/min/1.73 m², as supported by the Kidney International guideline and the American College of Cardiology 1, 2
• Patients with chronic kidney disease (CKD) and type 2 diabetes should have persistent albuminuria (>30 mg/g) despite maximum tolerated renin-angiotensin-aldosterone system (RAS) inhibitor therapy to be considered for finerenone therapy, with a baseline serum potassium level of ≤4.8 mmol/L, as recommended by the Kidney International guideline 1
• Finerenone is contraindicated in patients with adrenal insufficiency and should not be initiated if eGFR is <25 mL/min/1.73 m² or serum potassium >4.8 mmol/L, as recommended by the Kidney International and American College of Cardiology guidelines 3, 1, 4

Monitoring and Follow-up

• Serum potassium levels should be checked at 1 month after initiation of finerenone and every 4 months thereafter, with a target level of ≤4.8 mmol/L, and finerenone should be held if serum potassium levels >5.5 mmol/L, as recommended by the Kidney International guideline 1
• Patients on finerenone should be monitored for serum potassium and renal function at baseline, 1 month after initiation, and every 4 months thereafter, and discontinue finerenone if serum potassium >5.5 mmol/L despite medical management or if severe hyperkalemia requiring emergency intervention occurs, as recommended by the American Heart Association, American College of Cardiology, and European Society of Cardiology guideline societies 3, 1, 5, 6, 2, 7

Efficacy and Safety

• Nonsteroidal MRAs, such as finerenone, reduce kidney disease progression by 23% (hazard ratio 0.77, 95% confidence interval: 0.67-0.88), cardiovascular events by 14% (hazard ratio 0.86, 95% confidence interval: 0.78-0.95), and hospitalization for heart failure by 29% (hazard ratio 0.71, 95% confidence interval: 0.56-0.90) in patients with type 2 diabetes and CKD, based on high-quality evidence from the FIDELIO-DKD and FIGARO-DKD trials, as recommended by the American College of Cardiology and supported by the Kidney Disease: Improving Global Outcomes (KDIGO) organization 8
• The incidence of hyperkalemia in the FIGARO-DKD and FIDELIO-DKD studies is as follows:

5, 8, 7

• Nonsteroidal MRAs have a more balanced tissue distribution, more potent anti-inflammatory/anti-fibrotic effects, lower risk of hyperkalemia, and minimal hormonal side effects compared to steroidal MRAs, with a moderate strength of evidence, as suggested by the European Renal Association 2

Combination Therapy

• Nonsteroidal MRAs can be effectively combined with SGLT2 inhibitors, GLP-1 receptor agonists, and metformin (if eGFR >30 ml/min/1.73 m²) to provide additive cardiorenal protection in patients with type 2 diabetes and CKD, with a moderate to high strength of evidence, as recommended by the American Heart Association and supported by the American Diabetes Association and Kidney International guidelines 2, 9, 1, 10, 5, 3, 8, 6
• The Kidney International guideline suggests that finerenone can be safely combined with SGLT2 inhibitors for additive cardiorenal protection, without requiring dose adjustment of SGLT2 inhibitors 1

Ongoing Research

• The FIND-CKD trial (NCT05047263) is currently investigating finerenone in adults with non-diabetic CKD, including 1,584 patients with UACR ≥200-≤3500 mg/g and eGFR ≥25-<90 ml/min/1.73 m², with the most common causes being chronic glomerulonephritis (57.0%) and hypertensive/ischemic nephropathy (29.0%) 11
• The FIONA program is investigating finerenone in children with glomerular and non-glomerular CKD, providing potential future data on the efficacy and safety of finerenone in pediatric populations 11