Finerenone is associated with pronounced uric acid reduction in hyperuricemic diabetic kidney disease: a real-world...

Diabetic kidney disease (DKD) is a critical complication of type 2 diabetes, often compounded by hyperuricemia, which may accelerate renal function decline. While finerenone, a nonsteroidal mineralocorticoid receptor antagonist (MRA), provides renal and cardiovascular benefits, its impact on uric acid (UA) metabolism in real-world DKD patients, particularly those with high baseline SUA, remains controversial.

In this retrospective, single-center study, we included 124 patients with type 2 DKD (baseline eGFR ≥60 mL/min/1.73 m²) who initiated finerenone. Patients with recent gout or urate-lowering therapy were excluded. Changes in SUA, urinary albumin-to-creatinine ratio (UACR), and eGFR were assessed before and after 1-3 months of treatment. Statistical analyses employed linear mixed models for longitudinal data and multivariable regression.

Linear mixed model analysis showed finerenone treatment was associated with a significant reduction in SUA (adjusted mean difference: -47.9 μmol/L, 95% CI: -63.5 to -32.3; p < 0.001). This reduction was substantially greater in patients with baseline hyperuricemia (-88.6 μmol/L) than in those without (-16.6 μmol/L; p for interaction = 0.003). UACR decreased by 39.4% (p < 0.001), while eGFR showed a small but significant decline (-2.7 mL/min/1.73 m², p = 0.019). The SUA-lowering association was independent of concomitant SGLT2 inhibitor or GLP-1 receptor agonist use in multivariable analyses. Hyperkalemia (potassium ≥5.5 mmol/L) occurred in 0.8% of patients.

In this real-world cohort, finerenone use was associated with significant reductions in albuminuria and SUA, particularly among patients with hyperuricemia. These findings suggest a potential dual benefit in this high-risk subgroup and highlight the importance of baseline SUA in interpreting finerenone's metabolic effects. The observed SUA reduction warrants further prospective investigation.