Longitudinal kidney outcomes and safety after finerenone initiation in patients with non-diabetic chronic kidney disease: a single-center retrospective cohort study

Abstract

Finerenone, a non-steroidal mineralocorticoid receptor antagonist, has demonstrated renoprotective effects in randomized controlled trials. However, real-world evidence, particularly in heterogeneous and non-diabetic chronic kidney disease (CKD) populations, remains limited. This was a single-center, retrospective, real-world cohort study of adults with non-diabetic CKD who initiated finerenone. Longitudinal changes in urinary albumin-to-creatinine ratio (UACR) and 24 h urinary protein (24 hUP) were analyzed using covariate-adjusted gamma-log generalized estimating equation (GEE) models with an autoregressive correlation structure of order 1 [AR(1)] and robust standard errors, whereas eGFR trajectories were evaluated using a covariate-adjusted segmented linear mixed-effects model. The UACR and 24 hUP models were adjusted for age, sex, RASi use, SGLT−2i use, and immunosuppressant use; the eGFR model additionally included baseline UACR category. Subgroup heterogeneity was assessed using interaction tests, with Benjamini–Hochberg false discovery rate correction. Among 121 patients, finerenone initiation was associated with reductions in UACR and 24 hUP. The adjusted changes in UACR were −48.6% at Month 12 (95% CI, −60.1% to −33.8%; P  < 0.001) and −35.4% at Month 24 (95% CI, −63.4% to 14.0%; P  = 0.132). The corresponding adjusted changes in 24 hUP were −34.5% (95% CI, −47.3% to −18.6%; P  < 0.001) and −34.9% (95% CI, −56.6% to −2.4%; P  = 0.038), respectively. The annualized eGFR slope attenuated from −6.51 mL/min/1.73 m 2 /year (95% CI, −9.70 to −3.31) before finerenone initiation to −1.44 mL/min/1.73 m 2 /year (95% CI, −3.52 to 0.64) after initiation, corresponding to a slope improvement of 5.07 mL/min/1.73 m 2 /year (95% CI, 1.86 to 8.27; P  = 0.002). No serious adverse events were documented during follow-up; hyperkalemia occurred in 4.96% of patients, and neither hyperkalemia nor hypotension prompted treatment discontinuation. In this real-world cohort, finerenone was associated with reductions in UACR and 24 hUP and attenuation of eGFR decline, with infrequent observed hyperkalemia and hypotension during the available follow-up.