Additive Cardiorenal Benefits of Finerenone and SGLT2 Inhibitor Combination Therapy in Diabetic CKD: A...

Finerenone and sodium-glucose cotransporter-2 inhibitors (SGLT2i) independently improve cardiovascular and renal outcomes in diabetic chronic kidney disease (CKD), but real-world evidence on their combined use is understudied. Using the TriNetX Global Collaborative Network, we identified adults with CKD and type 2 diabetes who initiated SGLT2i therapy between July 2020 and December 2024. Patients receiving SGLT2i monotherapy were compared with those who subsequently added finerenone. After excluding end-stage kidney disease and prior mineralocorticoid receptor antagonist use, cohorts were propensity-score matched (1:1) across 31 covariates. Outcomes included all-cause mortality, major adverse cardiovascular events (MACE), major adverse kidney events (MAKE), hyperkalemia, and a negative-control outcome (osteoarthritis). Associations were estimated using risk ratios, hazard ratios, and Kaplan-Meier survival analyses. After matching, 2,317 patients were included in each cohort. Over 1 year, finerenone use was associated with significantly lower all-cause mortality (HR 0.37; 95% CI: 0.25 to 0.55). Rates of MACE (HR 0.89, 95% CI: 0.74 to 1.09) and MAKE (HR 0.95; 95% CI: 0.47 to 1.92) were similar between groups. Hyperkalemia occurred more often with finerenone (HR 1.35; 95% CI: 1.11 to 1.69) although risk-based analyses did not reach statistical significance. Osteoarthritis rates did not differ. In conclusion, adding finerenone to SGLT2i therapy was associated with lower mortality and favorable cardiovascular outcomes without excess kidney risk, supporting complementary cardiorenal benefits with appropriate potassium monitoring.