Finerenone in Chronic Kidney Disease: A Comprehensive Review of Mechanisms, Efficacy and Safety

Chronic kidney disease (CKD) is a major global health issue that significantly impacts patients' quality of life and places a substantial burden on healthcare systems. Overactivation of the mineralocorticoid receptor (MR) plays a crucial role in kidney damage by promoting inflammation, fibrosis, and functional deterioration. Finerenone, a third-generation highly selective non-steroidal MR antagonist (MRA), has emerged as a promising therapeutic option for CKD. In this review, we discuss the mechanisms through which MR overactivation contributes to renal damage, the structural and pharmacokinetic characteristics of finerenone, and compare it with first- and second-generation MRAs. We also focus on the safety and efficacy of finerenone in clinical applications for CKD. Notably, finerenone demonstrated a reduction in the risk of hyperkalemia during treatment, with its high selectivity minimising treatment-related hormonal imbalances, offering a novel perspective. Furthermore, we explore the promising future of finerenone in both diabetic kidney disease (DKD) and non-diabetic CKD, presenting updates from recent clinical trials and new insights into its potential role in these populations. In clinical practice, combining finerenone with sodium-glucose cotransporter-2 (SGLT-2) inhibitors and renin-angiotensin system (RAS) inhibitors has demonstrated strong cardiorenal protective effects. However, further clinical evidence is needed regarding direct combinations of finerenone with RAS inhibitors. Future studies on their synergistic effects may provide valuable insights. Ultimately, we hope this review offers new perspectives on finerenone's clinical applications and its future therapeutic prospects.