Efficacy and safety of finerenone in patients with an acute change in estimated glomerular filtration rate in the prespecified FIDELITY pool analysis.

Navaneethan SD, Anker SD, Filippatos G, Pitt B, Rossing P, Ruilope LM, August P, Brinker M, Lage A, Roberts L, Scott C, Sarafidis P, FIDELIO-DKD and FIGARO-DKD Investigators. Efficacy and safety of finerenone in patients with an acute change in estimated glomerular filtration rate in the prespecified FIDELITY pool analysis. Kidney international. 2025 Jul 1; 108(1):136-144, DOI: 10.1016/j.kint.2025.03.018.

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Abstract:

INTRODUCTION: The efficacy and safety of finerenone (a nonsteroidal mineralocorticoid receptor antagonist) versus placebo were assessed according to different changes in estimated glomerular filtration rate (eGFR) using data from FIDELITY, a pooled individual-level analysis of two clinical trials. METHODS: Patients had chronic kidney disease (eGFR of 25 ml/min/1.73 m or greater) and type 2 diabetes with optimized renin-angiotensin system blockade. Risk of composite cardiovascular and composite kidney outcomes was analyzed by baseline eGFR change at month one in the total population and by treatment group. RESULTS: Of 12,798 patients, 25.1% had a > 10% eGFR decline, 31.2% had a > 0-10% decline, 26.8% had a 0-10% increase, and 16.8% had a > 10% increase after one month of treatment. Factors associated with acute eGFR decline included higher baseline urine albumin-to-creatinine ratio, eGFR, systolic blood pressure, diuretic or beta-blocker use, and finerenone use. Finerenone significantly reduced composite cardiovascular and kidney outcomes overall and had similar beneficial effect across eGFR subgroups of > 10% decline, > 0-10% decline, 0-10% increase, and > 10% increase for composite cardiovascular (hazard ratio [95% Confidence Interval] of 0.74 [0.61-0.90], 0.87 [0.73-1.04], 1.06 [0.87-1.28], and 0.78 [0.61-0.99], respectively) and kidney outcomes (0.67 [0.53-0.85], 0.78 [0.61-1.01], 0.56 [0.40-0.77], and 0.75 [0.50-1.14], respectively) (P interaction 0.048 and 0.23, respectively). When modeled as a continuous variable, finerenone reduced the risk of cardiovascular and kidney outcomes, irrespective of acute eGFR change (P interaction 0.58 and 0.36, respectively). CONCLUSIONS: The cardiovascular and kidney benefits of finerenone were not modified by an acute eGFR change after drug initiation.