Non-steroidal MRA reduces kidney outcomes in patients with CKD and T2DM

Effect of Finerenone on Chronic Kidney Disease Outcomes in Type 2 Diabetes

Literature - Bakris GL, Agarwal R, Anker SD, et al. - N Eng J Med, 2020, DOI: 10.1056/NEJMoa2025845

Introduction and methods

Clinical strategies for the management of CKD in patients with T2DM include treatment with an angiotensin receptor blocker (ARB) or an angiotensin-converting-enzyme (ACE) inhibitor, or a sodium glucose co-transporter (SGLT2) inhibitor to control hypertension and hyperglycemia [1,2]. However, a risk of CKD progression still remains, showing the need for newer therapies.

Aldosterone binds to the mineralocorticoid receptor (MR), leading to sodium absorption and potassium excretion, thereby controlling fluid and electrolyte status as well as blood pressure. Overactivation of the MR has been associated with the development of cardiorenal diseases such as CKD and diabetes, through increased levels of inflammatory cytokines and profibrotic factors [3]. Although a meta-analysis showed a reduction of 31% in urinary protein or albumin excretion after steroidal MR-antagonist (MRA) treatment in patient with CKD, data on hard clinical outcomes are lacking [4].

The dihydropyridine finerenone is a nonsteroidal, selective antagonist of the MR, and showed in preclinical models, more potent anti-inflammatory and antifibrotic effects than steroidal MRAs [5-8]. Also, patients with T2DM and CKD treated with finerenone had reduced albumin-to-creatinine ratio compared to those treated with a RAS blocker and smaller effects on serum potassium levels compared to those treated with spironolactone [9,10].

This study assessed the long-term efficacy and safety of finerenone on kidney and CV outcomes in patients with advanced CKD and T2DM.

The phase 3 Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) trial was a double-blind, placebo-controlled, randomized (1:1), multicenter trial. Patients (n=5674, ≥18 years) diagnosed with type 2 diabetes and CKD receiving an ACE-inhibitor or ARB medication at maximum tolerable dose were included in the study and randomized to finerenone or placebo. Baseline potassium concentration levels had to be 4.8 mmol/L or less and eGFR levels had to be stable. CKD was defined as persistent moderately elevated albuminuria (urinary albumin-to-creatinine ratio [UACR] of 30 to<300 mg/g) and an eGFR of 25 to <60 mL/min/1.73m² and a history of diabetic retinopathy or persistent, severely elevated albuminuria (UACR of 300-5000 mg/g) and a eGFR of 25-<75 mL/min/1.73m². The primary outcome was a composite of kidney failure defined as end-stage kidney disease (dialysis ≥90 days or kidney transplantation) or an eGFR <15mL/min/1.73m², sustained decrease of ≥40% of eGFR in ≥4 weeks, or renal death. The secondary CV outcome was a composite of CV death, non-fatal MI, non-fatal stroke, or HF hospitalization. Other secondary outcomes were all-cause death, change in UACR from baseline to 4 months and a composite of kidney failure, sustained decrease of ≥57% of eGFR from baseline for a minimum of 4 weeks or renal death. Median follow-up was 2.6 years.

Main results

  • The incidence of the primary outcome was significantly lower in patients receiving finerenone (17.8%) compared to patients in the placebo group (21.1%). This resulted in an HR of 0.82 (95% CI:0.73-0.93, P=0.001).
  • The number of patients needed to treat (NNT) with finerenone to prevent one primary outcome event was 29 (95% CI: 16-166).
  • Patients treated with finerenone had a 13% lower risk of the composite of CV death, non-fatal MI, nonfatal stroke, or hospitalization due to HF compared to 14.5% of patients receiving placebo (HR 0.86, 95% CI:0.75-0.99, P=0.03).
  • The NNT with finerenone was 42 (95% CI: 22-397) for the secondary CV composite outcome. All-cause death was not different between the finerenone and placebo groups.
  • Patients on finerenone had, from baseline to 4 month treatment, 31% reduction in UACR compared to placebo. Patients receiving finerenone had reduced UACR levels throughout the study.
  • 8.9% Of patients treated with finerenone had a secondary composite kidney outcome, compared to 11.5% in the placebo group (HR 0.76, 95% CI:0.65-0.90).
  • Serious adverse events were well balanced between the two groups (31.9% in the finerenone group vs. 34.3% in the placebo group). Overall hyperkalemia-related adverse events were twice as common with finerenone as with placebo (18.3% vs. 9.0%, respectively) and frequency of hyperkalemia leading to discontinuation of study regimen was 2.3% in the finerenone group and 0.9% in the placebo group. 21.7% Of patients receiving finerenone had elevated serum potassium levels of more than 5.5 mmol/L compared to 9.8% in the placebo group.


Patients with T2DM and CKD, who received finerenone had a significant lower risk of a primary kidney event compared to patients treated with placebo. In addition, a composite of CV events was reduced by finerenone in these patients when compared to placebo.


1. American Diabetes Association. 11. Microvascular complications and foot care: Standards of Medical Care in Diabetes — 2020. Diabetes Care 2020; 43: Suppl 1: S135-S151.

2. Buse JB, Wexler DJ, Tsapas A, et al. 2019 update to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2020; 63: 221-8.

3. Barrera-Chimal J, Girerd S, Jaisser F.Kidney, et al. Mineralocorticoid receptor antagonists and kidney diseases: pathophysiological basis. 2019;96:302-319.

4. Currie G, Taylor AHM, Fujita T, et al. Effect of mineralocorticoid receptor antagonists on proteinuria and progression of chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 2016; 17: 127.

5. Grune J, Beyhoff N, Smeir E, et al. Selective mineralocorticoid receptor cofactor modulation as molecular basis for finerenone’s antifibrotic activity. Hypertension 2018; 71:599-608.

6. Kolkhof P, Delbeck M, Kretschmer A, et al. Finerenone, a novel selective nonsteroidal mineralocorticoid receptor antagonist protects from rat cardiorenal injury. J Cardiovasc Pharmacol 2014; 64: 69-78.

7. Kolkhof P, Jaisser F, Kim SY, Filippatos G, Nowack C, Pitt B. Steroidal and novel non-steroidal mineralocorticoid receptor antagonists in heart failure and cardiorenal diseases: comparison at bench and bedside. Handb Exp Pharmacol 2017;243: 271-305.

8. Agarwal R, Kolkhof P, Bakris G, et al. Steroidal and non-steroidal mineralocorticoid receptor antagonists in cardiorenal medicine. Eur Heart J (in press).

9. Bakris GL, Agarwal R, Chan JC, et al. Effect of finerenone on albuminuria in patients with diabetic nephropathy: a randomized clinical trial. JAMA 2015; 314:884-94.

10. Pitt B, Kober L, Ponikowski P, et al. Safety and tolerability of the novel nonsteroidal mineralocorticoid receptor antagonist BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease: a randomized, double-blind trial. Eur Heart J 2013; 34:2453-63.

Find this article online at New Eng J Med.

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