Finerenone in diabetic chronic kidney disease-Real-world insights including patients with HFpEF or HFmrEF.

Purpose: Finerenone, a highly selective non-steroidal mineralocorticoid receptor antagonist, was approved for the treatment of patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (diabetic kidney disease, DKD). Finerenone reduced the composite endpoint of heart failure events and cardiovascular death in patients with heart failure with preserved or mildly reduced ejection fraction (HFpEF/HFmrEF). This study aimed to investigate the safety and cardiac effects of finerenone in patients with DKD with or without HFpEF/HFmrEF in a real-world setting.

Methods: Patients with DKD were prospectively enrolled and were treated with finerenone according to best clinical practice. Clinical, laboratory and echocardiographic assessments were performed before, 4 weeks and 6 months after starting finerenone.

Results: Thirty-one patients with DKD were included. At baseline, patients had a typical risk profile with arterial hypertension (90.3%) and hyperlipoproteinemia (87.1%). Most patients were treated with a sodium-glucose cotransporter 2 (SGLT2) inhibitor (93.5%). Treatment with finerenone was safe and well tolerated: after 4 weeks, the glomerular filtration rate decreased slightly from 52 (43-78) mL/min/1.73 m² to 48.0 (39.0-71.0) mL/min/1.73 m² (P = 0.002 vs. baseline), but stabilized thereafter. Similarly, the median potassium value increased from 4.2 (3.8-4.5) mmol/L to 4.4 (4.2-4.8) mmol/L (P = 0.017) after 4 weeks, but remained stable thereafter [4.4 (4.1-4.6) mmol/L (P = 0.079)]. Only one patient (3.2%) had an unplanned hospitalization and concomitant hyperkalaemia up to 6.0 mmol/L. HFpEF/HFmrEF was frequently found in patients with DKD (71.0%), although most patients had a rather early stage with only mild symptoms and a median N-terminal pro B-type natriuretic peptide (NT-proBNP) value of 150.8 (54.5-325.7) ng/L. During treatment with finerenone, NT-proBNP and left ventricular mass index (LVMI) remained stable. In contrast, left atrial volume index (LAVI) decreased from baseline [31.2 (26.8-39.7) mL/m²] to 4 weeks follow-up [29.7 (20.8-33.6) mL/m², P = 0.027] and decreased further after 6 months [26.6 (20.8-34.9) mL/m², P = 0.029]. In the subgroup of patients with HFpEF/HFmrEF, E/e' decreased from 11.9 (8.7-14.5) at baseline to 9.9 (8.0-12.4) after 6 months (P = 0.043).

Conclusions: In a real-world setting, treatment with finerenone is safe and well-tolerated in patients with DKD and may improve functional and structural cardiac parameters. Further investigation is warranted.