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.