Finerenone and Cardiorenal Outcomes: A Narrative Review

Finerenone is a nonsteroidal mineralocorticoid receptor antagonist that has demonstrated cardiorenal benefits in patients with chronic kidney disease (CKD) associated with type 2 diabetes. CKD affects up to 40% of patients with type 2 diabetes and is associated with substantial cardiovascular morbidity and mortality. Despite renin-angiotensin system inhibitors and sodium-glucose cotransporter-2 inhibitor therapy, many patients experience worsening kidney function and cardiovascular events. This narrative review summarizes evidence published between 2014 and 2025, including Mineralocorticoid Receptor Antagonist Tolerability Study-Diabetic Nephropathy, Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease, Finerenone in Reducing Cardiovascular Mortality and Morbidity in Diabetic Kidney Disease, pooled analysis of FIDELIO-DKD and FIGARO-DKD, and Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients With Heart Failure, and relevant real-world studies. Finerenone provides organ protection by reducing mineralocorticoid receptor-mediated inflammation and fibrosis, offering benefits beyond blood pressure and glycemic control. Clinical trials have shown an approximate 30% drop in urine albumin-to-creatinine ratio within the first months of treatment, with a slower long-term decline in kidney function. The pooled analyses indicate a 23% reduction in serious kidney outcomes and a 14% reduction in major cardiovascular events compared with placebo, in patients receiving background angiotensin-converting enzyme inhibitor or angiotensin receptor blocker therapy. Although hyperkalemia was more frequent with finerenone than placebo, discontinuation was uncommon under trial-based monitoring protocols. Overall, finerenone is an important addition to cardiorenal risk reduction in CKD associated with type 2 diabetes, although direct randomized endpoint comparisons with spironolactone or eplerenone remain lacking. Hyperkalemia risk should be interpreted in the context of trial eligibility criteria and structured potassium monitoring.