The Role of Finerenone in Cardiorenal Protection and Urine Albumin-to-Creatinine Ratio Modulation

Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) have a high risk of cardiovascular (CV) and kidney complications, largely driven by inflammation, fibrosis, and albuminuria. Despite advancements in standard therapies, many patients remain at high risk, necessitating new treatments that target these underlying mechanisms. Finerenone exerts antiinflammatory and antifibrotic effects, demonstrating a more favorable hyperkalemia profile than steroidal mineralocorticoid receptor antagonists (MRAs). Studies have demonstrated that finerenone significantly reduces the urinary albumin-to-creatinine ratio (UACR), with many patients achieving a ≥ 30% reduction in UACR, which mediates the treatment effect on kidney and CV outcomes. The FIDELIO-DKD and FIGARO-DKD trials, supported by the FIDELITY pooled analysis, highlight finerenone's ability to improve kidney and CV outcomes across diverse populations with CKD and T2D. Current guidelines, including those from the American Diabetes Association and Kidney Disease: Improving Global Outcomes, endorse finerenone for patients with CKD and T2D who have albuminuria and an estimated glomerular filtration rate (eGFR) ≥ 25 ml/min per 1.73 m². These recommendations emphasize its role in reducing the residual risk of CKD progression and CV complications. Finerenone represents an important advancement in the management of CKD and T2D, offering substantial benefits in UACR modulation and cardiorenal protection. By examining its clinical efficacy and safety profile, this review aims to provide a comprehensive understanding of how finerenone contributes to improved outcomes for patients with CKD and T2D, emphasizing its position as a pivotal component of contemporary treatment strategies.