Association between finerenone use and risk of new-onset heart failure in chronic kidney disease: a propensity-matched cohort study using the TriNetX network

Finerenone improves cardiorenal outcomes in chronic kidney disease (CKD) with type 2 diabetes, but its effect on preventing new-onset heart failure (HF) in CKD is uncertain. We evaluated whether finerenone is associated with lower 1-year risk of incident HF and adverse cardiorenal events in CKD patients without prior HF.

In the multi-institutional TriNetX research network, we identified adults with CKD between January 1, 2022, and September 30, 2025. New users of finerenone were compared with finerenone non-users. Propensity score matching (1:1) was performed based on demographics, comorbidities, medications, and key laboratory values. Follow-up began the day after the index date and continued for up to 1 year. The primary outcome was new-onset HF. HF was identified using diagnostic codes and treatment-based criteria; therefore, outcome misclassification cannot be completely excluded. Secondary outcomes were major adverse cardiovascular events (MACE: ischemic stroke, acute myocardial infarction, or death), major adverse kidney events (MAKE), and all-cause mortality. Cox models estimated hazard ratios (HRs) with 95% confidence intervals (CIs).

After matching, 11,140 patients were included (mean age 67.5 years, 42.5% female). Finerenone use was associated with a lower 1-year risk of incident HF (4.9% vs. 8.0%; HR 0.68, 95% CI 0.59-0.79; P<.001). Finerenone use was also associated with lower risks of MACE (HR 0.67, 95% CI 0.56-0.81; P<.001), MAKE (HR 0.51, 95% CI 0.39-0.67), and all-cause mortality (HR 0.62, 95% CI 0.47-0.81; P<.001).

In this large real-world CKD cohort without prior HF, finerenone use was associated with lower 1-year risks of incident HF, MACE, MAKE, and all-cause mortality compared with non-use. These findings suggest a potential association between finerenone use and a lower observed risk of HF among patients with CKD, although causal relationships cannot be established.