Non-steroidal mineralocorticoid receptor antagonists: a paradigm shift in the management of diabetic nephropathy

Background: Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) worldwide. The management of DKD relies on controlling glycaemia and blood pressure levels, as well as reducing proteinuria. While the traditional renin-angiotensin-aldosterone system inhibitors (RAASi) and the recently approved Type 2 Na+/Glucose co-transporter inhibitors (SGLT2i) have significantly improved patient outcomes, residual risks remain unaddressed. Summary: This review explores (i) the mechanisms of action of finerenone, a novel non-steroidal mineralocorticoid receptor antagonist (ns-MRA), (ii) the evidence of finerenone-induced kidney protection in clinical trials, and (iii) the comparative advantages over conventional MRAs. The potential synergy between finerenone and SGLT2i is also addressed, alongside research perspectives and practical considerations for implementation in clinical practice. Key Messages: Finerenone has emerged as a breakthrough therapy in the management of DKD, demonstrating robust nephron- and cardio-protective effects.