Finerenone and Cardiovascular Outcomes in Patients With Chronic Kidney Disease and Type 2 Diabetes

Mineralocorticoid Receptor Antagonists-Use in Chronic Kidney Disease

Mineralocorticoid receptor antagonists (MRA) are drugs with a potentially broad spectrum of action. They have been reported to have healing effects in many diseases, such as chronic heart failure, hypertension, or nephrotic syndrome. Numerous studies suggest that mineralocorticoid receptor activation is pathogenic and a progression factor of chronic kidney disease (CKD); however, results of studies on the use of MRA in the treatment of CKD are inconclusive. Current guidelines recommend against the use of MRA in patients with advanced CKD. Although, there is growing interest on their use in this population due to treatment benefits. In this review, we summarize studies which were purposed to evaluate the impact of MRA therapy on CKD patients. Despite many benefits of this treatment e.g., reducing cardiovascular mortality or alleviating proteinuria, steroidal MRA (such as spironolactone or eplerenone) have a low safety profile. They often lead to hyperkalemia complications which are dangerous in patients with CKD, and diabetic nephropathy, especially in hemodialysis patients. Studies on recently developed nonsteroidal MRA showed that they have fewer side effects. In our review, we discuss steroidal and nonsteroidal MRA treatment effects on the estimated glomerular filtration rate (eGFR), proteinuria, the cardiovascular system, and hyperkalemia in CKD patients. We present new content and recent publications in this field.

Nonsteroidal mineralcorticoid receptor antagonists: Novel therapeutic implication in the management of patients with type 2 diabetes

Growing evidencehas described a correlation between aldosterone, obesity, and insulin resistance, suggesting that adipocyte-related factors and mineralocorticoid receptor (MR) overactivation may alter aldosterone secretion, potentially leading to obesity and glucose intolerance. Preclinical studies showed that pharmacological antagonism of MR prevents white adipose tissue dysfunction(s) and expansion, activates brown adipose tissue, and improves glucose tolerance. The clinical use of nonsteroidal MR antagonists has been shown to reduce the risk of diabetic kidney disease progression and cardiovascular events in patients with diabetes. This review aims to summarize the effects of pharmacological MR blockade on obesity and its associated metabolic comorbidities, with a particular focus on the therapeutic implications of nonsteroidal MR antagonists in the management of patients with diabetes.

Mineralocorticoid receptors in pulmonary hypertension and right heart failure: From molecular biology to therapeutic targeting

Pulmonary hypertension (PH) is a devastating condition characterized by pulmonary vascular remodelling, leading to progressive increase in pulmonary artery pressure and subsequent right ventricular failure. Aldosterone and the mineralocorticoid receptor (MR), a nuclear transcription factor, are key drivers of cardiovascular disease and MR antagonists are well-established in heart failure. Now, a growing body of evidence points at a detrimental role of MR in PH. Pharmacological MR blockade attenuated PH and prevented RV failure in experimental models. Mouse models with cell selective MR deletion suggest that this effect is mediated by MR in endothelial cells. While the evidence from experimental studies appears convincing, the available clinical data on MR antagonist use in patients with PH is more controversial. Integrated analysis of clinical data together with MR-dependent molecular alterations may provide insights why some patients respond to MRA treatment while others do not. Potential ways to identify MRA 'responders' include the analysis of underlying PH causes, stage of disease, or sex, as well as new biomarkers.

Nonsteroidal mineralocorticoid receptor antagonism for cardiovascular and renal disorders - New perspectives for combination therapy

During the recent 30 years, there has been a dramatic increase in knowledge about the role of aldosterone and the mineralocorticoid receptor (MR) in the pathophysiology of cardiovascular (CV) and kidney diseases. The scientific perspective on the aldosterone/MR ensemble extended from a previously renal epithelial-centered focus on sodium-potassium exchange to a broader view as systemic modulators of extracellular matrix, inflammation and fibrosis. Spironolactone was launched as the first antagonist of aldosterone 27 years before the MR was cloned. It was classified as a potassium-sparing diuretic, based on its initial clinical characterization as a diuretic and its preferred activity to compensate for the potassium loss induced by loop diuretics when used in combination. The second steroidal MR antagonist was eplerenone which was discovered at a time when the role of aldosterone and MR in cardiac fibrosis was rediscovered. The constraint of developing potentially life-threatening hyperkalaemia when used in combination with other inhibitors of the renin-angiotensin-system (RAS) in patients with reduced kidney function initiated extensive research and development activities with the goal to identify novel nonsteroidal MR antagonists with an improved benefit-risk ratio. Here we summarize major current clinical trials with MRAs in different CV and renal diseases. Addition of the nonsteroidal MRA finerenone to optimal RAS blockade recently reduced CV and kidney outcomes in two large phase III trials in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D). We provide an outlook on further opportunities for combination therapy of nonsteroidal MRA finerenone with RAS inhibitors and sodium-glucose cotransporter-2 inhibitors (SGLT2i).

Prevalence of Chronic Kidney Disease in Type 2 Diabetes: The Canadian REgistry of Chronic Kidney Disease in Diabetes Outcomes (CREDO) Study

PURPOSE

Chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) is associated with an elevated risk of end-stage kidney disease, cardiovascular disease (CVD), and death. As the breadth of treatment options for CKD in patients with T2D (CKD in T2D) continues to expand, an analysis of the current use of therapies and cardiovascular and kidney outcomes is necessary. The objectives of the study were to assess the prevalence of CKD in T2D among a contemporary cohort of patients, to describe patient characteristics and treatment patterns, and to examine health care practitioner rationale for initiating therapies.

METHODS

The study was a retrospective, observational study (module A) with a prospective component (module B). For module A, sociodemographic data, medical history, prescription information, and laboratory investigations for patients seen by an endocrinologist in 2019 were retrieved from the LMC Diabetes Registry. Module B included a subset of patients for health care practitioner surveys to understand rationale for administering angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs), steroidal mineralocorticoid receptor antagonists (MRAs), sodium-glucose cotransporter 2 inhibitors (SGLT2is), and glucagon-like peptide 1 receptor agonists (GLP-1RAs). Descriptive analyses were conducted.

FINDINGS

The study included 14,873 patients (59% male). Mean patient age was 67 years, mean body mass index was 31 kg/m², and mean glycosylated hemoglobin was 7.6%. Mean diabetes duration was 16 years. The prevalence of CKD in patients with T2D was 47.9%. Common comorbidities were hypertension (76%), dyslipidemia (71%), and obesity (51%). CVD was reported in 22%. The proportion of kidney medications and emerging therapies varied, with 76% of patients using an ACEi or ARB, 48% using an SGLT2i, 30% using a GLP-1RA, and 3% using a steroidal MRA. In module B, physicians identified that ACEis/ARBs, SGLT2is, GLP-1RAs, or steroidal MRAs were administered to primarily treat CKD in 33%, 12%, 0%, and 4% of the patients (n = 500), respectively.

IMPLICATIONS

These findings improved our understanding of the current landscape and treatment patterns of CKD inT2D and highlighted the importance of considering treatments that will provide a comprehensive strategy for cardiovascular and kidney risk protection. Despite the high prevalence of CKD and comorbidities reported in a large, Canadian T2D specialist population, ACEis/ARBs, SGLT2is, and GLP-1RAs were underused, especially considering recent clinical trial reports. The relative use of steroidal MRAs was expectedly low. With an immense burden of CKD progression and among patients with T2D, the use of treatments that provide a comprehensive strategy for kidney protection will transform the landscape of CKD in T2D. ClinicalTrials.gov identifier: NCT04445181.

Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies

Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K⁺) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K⁺ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K⁺ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K⁺ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.

Intersection Between Chronic Kidney Disease and Cardiovascular Disease

PURPOSE OF REVIEW

The incidence of chronic kidney disease is increasing worldwide, and the previously decreasing incidence of cardiovascular disease has now plateaued. Understanding the intersection of both heart and kidney disease is crucial.

RECENT FINDINGS

Chronic kidney disease and cardiovascular disease share common risk factors and specific pathogenic mechanisms and impact a significant segment of the population. Patients with chronic kidney disease are more likely to have cardiovascular disease than progress to end-stage kidney disease requiring renal replacement therapy. We discuss shared risk factors and mechanisms for cardiovascular and chronic kidney disease. The following also addresses contemporary cardiovascular treatment considerations in patients with chronic kidney disease with a focus on atherosclerotic cardiovascular disease and heart failure.

Signaling Pathways Involved in Diabetic Renal Fibrosis

Diabetic kidney disease (DKD), as the most common complication of diabetes mellitus (DM), is the major cause of end-stage renal disease (ESRD). Renal interstitial fibrosis is a crucial metabolic change in the late stage of DKD, which is always considered to be complex and irreversible. In this review, we discuss the pathological mechanisms of diabetic renal fibrosis and discussed some signaling pathways that are closely related to it, such as the TGF-β, MAPK, Wnt/β-catenin, PI3K/Akt, JAK/STAT, and Notch pathways. The cross-talks among these pathways were then discussed to elucidate the complicated cascade behind the tubulointerstitial fibrosis. Finally, we summarized the new drugs with potential therapeutic effects on renal fibrosis and listed related clinical trials. The purpose of this review is to elucidate the mechanisms and related pathways of renal fibrosis in DKD and to provide novel therapeutic intervention insights for clinical research to delay the progression of renal fibrosis.

The Role of Finerenone in the Management of Diabetic Nephropathy

Diabetic nephropathy (DN) is the leading cause of chronic kidney disease. Even though mineralocorticoid receptor antagonists (MRA) induce incremental reductions in urine albumin excretion when added to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, this combination is infrequently used because of an increased risk of hyperkalemia. In this context, finerenone, a novel selective MRA that appears to be associated with lower risk for hyperkalemia compared with other MRAs (spironolactone and eplerenone), might represent a useful tool in patients with DN. A recent large randomized trial suggested that finerenone delays the progression of DN and might also reduce cardiovascular morbidity in patients with DN. However, more data are needed to clarify the safety and efficacy of finerenone in this high-risk population.

Interplay between worsening kidney function and cardiovascular events in patients with type 2 diabetes: an analysis from the ACCORD trial

INTRODUCTION

Patients with type 2 diabetes (T2D) have an increased risk of worsening kidney function (WKF) over time compared with patients without diabetes. Data evaluating the inter-relation between WKF, cardiovascular risk, and clinical events are scarce. We aim to study the association of WKF with subsequent cardiovascular events and the probabilities of transition from WKF to hospitalization or death according to patients' risk. We have used a large population of patients with T2D and a high cardiovascular risk enrolled in the Action to Control Cardiovascular Risk in Diabetes Study.

RESEARCH DESIGN AND METHODS

Time-updated, joint, and multistate modeling were used. WKF was defined as an estimated glomerular filtration rate (eGFR) decline greater than 40% from baseline. A total of 10 251 patients were included, of whom 1213 (11.8%) presented WKF over a median (percentile_25-75) follow-up time of 5.0 (4.1-5.7) years.

RESULTS

Patients who experienced WKF were slightly older, more frequently women, and had longer diabetes duration. Patients experiencing WKF, regardless of baseline kidney function, had a higher risk of subsequent cardiovascular events, including the composite of cardiovascular death or hospitalization for heart failure (HHF), with ≈2-fold higher risk. Joint modeling showed that renal function deterioration frequently occurs even among patients who did not experience a cardiovascular event. In multistate models, patients with a medium-high cardiovascular risk (compared with those with a low cardiovascular risk) are at higher risk of HHF or cardiovascular death first (HR=4.76, 95% CI 3.63 to 6.23) than of WKF first (HR=1.37, 95% CI 1.21 to 1.56); remarkably, the risk of cardiovascular death or HHF is highest after a WKF event (HR=6.20, 95% CI 2.71 to 14.8).

CONCLUSIONS

In patients with T2D and a high cardiovascular risk, WKF occurs in more than 10% of patients and is independently associated with risk of subsequent cardiovascular events, irrespective of baseline eGFR. Preventing serious WKF and the transition from WKF to HHF or cardiovascular death is an important objective of future trials.

TRIAL REGISTRATION NUMBER

NCT00000620.

Management of Kidney Failure in Patients with Diabetes Mellitus: What Are the Best Options?

Diabetic kidney disease (DKD) is the most frequent cause of kidney failure (KF). There are large variations in the incidence rates of kidney replacement therapy (KRT). Late referral to nephrology services has been associated with an increased risk of adverse outcomes. In many countries, when patients reach severely reduced glomerular filtration rate (GFR), they are managed by multidisciplinary teams led by nephrologists. In these clinics, efforts will continue to halt chronic kidney disease (CKD) progression and to prevent cardiovascular mortality and morbidity. In patients with diabetes and severely reduced GFR and KF, treating hyperglycemia is a challenge, since some drugs are contraindicated and most of them require dose adjustments. Even more, a decision-making process will help in deciding whether the patient would prefer comprehensive conservative care or KRT. On many occasions, this decision will be conditioned by diabetes mellitus itself. Effective education should cover the necessary information for the patient and family to answer these questions: 1. Should I go for KRT or not? 2. If the answer is KRT, dialysis and/or transplantation? 3. Dialysis at home or in center? 4. If dialysis at home, peritoneal dialysis or home hemodialysis? 5. If transplantation is desired, discuss the options of whether the donation would be from a living or deceased donor. This review addresses the determinant factors with an impact on DKD, aiming to shed light on the specific needs that arise in the management and recommendations on how to achieve a comprehensive approach to the diabetic patient with chronic kidney disease.

Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease

Diabetes mellitus is a global health issue and main cause of chronic kidney disease. Both diseases are also linked through high cardiovascular morbidity and mortality. Diabetic kidney disease (DKD) is present in up to 40% of diabetic patients; therefore, prevention and treatment of DKD are of utmost importance. Much research has been dedicated to the optimization of DKD treatment. In the last few years, mineralocorticoid receptor antagonists (MRA) have experienced a renaissance in this field with the development of non-steroidal MRA. Steroidal MRA have known cardiorenal benefits, but their use is limited by side effects, especially hyperkalemia. Non-steroidal MRA still block the damaging effects of mineralocorticoid receptor overactivation (extracellular fluid volume expansion, inflammation, fibrosis), but with fewer side effects (hormonal, hyperkalemia) than steroidal MRA. This review article summarizes the current knowledge and newer research conducted on MRA in DKD.

Activation of Rac1-Mineralocorticoid Receptor Pathway Contributes to Renal Injury in Salt-Loaded db/db Mice

[Figure: see text].

Posttranslational Modifications of the Mineralocorticoid Receptor and Cardiovascular Aging

During aging, the cardiovascular system is especially prone to a decline in function and to life-expectancy limiting diseases. Cardiovascular aging is associated with increased arterial stiffness and vasoconstriction as well as left ventricular hypertrophy and reduced diastolic function. Pathological changes include endothelial dysfunction, atherosclerosis, fibrosis, hypertrophy, inflammation, and changes in micromilieu with increased production of reactive oxygen and nitrogen species. The renin-angiotensin-aldosterone-system is an important mediator of electrolyte and blood pressure homeostasis and a key contributor to pathological remodeling processes of the cardiovascular system. Its effects are partially conveyed by the mineralocorticoid receptor (MR), a ligand-dependent transcription factor, whose activity increases during aging and cardiovascular diseases without correlating changes of its ligand aldosterone. There is growing evidence that the MR can be enzymatically and non-enzymatically modified and that these modifications contribute to ligand-independent modulation of MR activity. Modifications reported so far include phosphorylation, acetylation, ubiquitination, sumoylation and changes induced by nitrosative and oxidative stress. This review focuses on the different posttranslational modifications of the MR, their impact on MR function and degradation and the possible implications for cardiovascular aging and diseases.

Finerenone Reduces New-Onset Atrial Fibrillation in Patients With Chronic Kidney Disease and Type 2 Diabetes

BACKGROUND

Patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) are at risk of atrial fibrillation or flutter (AFF) due to cardiac remodeling and kidney complications. Finerenone, a novel, selective, nonsteroidal mineralocorticoid receptor antagonist, inhibited cardiac remodeling in preclinical models.

OBJECTIVES

This work aims to examine the effect of finerenone on new-onset AFF and cardiorenal effects by history of AFF in the Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD) study.

METHODS

Patients with CKD and T2D were randomized (1:1) to finerenone or placebo. Eligible patients had a urine albumin-to-creatinine ratio ≥30 to ≤5,000 mg/g, an estimated glomerular filtration rate (eGFR) ≥25 to <75 ml/min/1.73 m² and received optimized doses of renin-angiotensin system blockade. Effect on new-onset AFF was evaluated as a pre-specified outcome adjudicated by an independent cardiologist committee. The primary composite outcome (time to first onset of kidney failure, a sustained decrease of ≥40% in eGFR from baseline, or death from renal causes) and key secondary outcome (time to first onset of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure) were analyzed by history of AFF.

RESULTS

Of 5,674 patients, 461 (8.1%) had a history of AFF. New-onset AFF occurred in 82 (3.2%) patients on finerenone and 117 (4.5%) patients on placebo (hazard ratio: 0.71; 95% confidence interval: 0.53-0.94; p = 0.016). The effect of finerenone on primary and key secondary kidney and cardiovascular outcomes was not significantly impacted by baseline AFF (interaction p value: 0.16 and 0.85, respectively).

CONCLUSIONS

In patients with CKD and T2D, finerenone reduced the risk of new-onset AFF. The risk of kidney or cardiovascular events was reduced irrespective of history of AFF at baseline. (EudraCT 2015-000990-11 [A randomized, double-blind, placebo-controlled, parallel-group, multicenter, event-driven Phase III study to investigate the efficacy and safety of finerenone, in addition to standard of care, on the progression of kidney disease in subjects with type 2 diabetes mellitus and the clinical diagnosis of diabetic kidney disease]; Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease [FIDELIO-DKD]; NCT02540993).

Cardiovascular Protection With Sodium-Glucose Cotransporter-2 Inhibitors and Mineralocorticoid Receptor Antagonists in Chronic Kidney Disease: A Milestone Achieved

Chronic kidney disease (CKD) and cardiovascular disease are intimately linked. They share major risk factors, including age, hypertension, and diabetes, and common pathogenetic mechanisms. Furthermore, reduced renal function and kidney injury documented with albuminuria are independent risk factors for cardiovascular events and mortality. In major renal outcome trials and subsequent meta-analyses in patients with CKD, ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin II receptor blockers) were shown to effectively retard CKD progression but not to significantly reduce cardiovascular events or mortality. Thus, a high residual risk for cardiovascular disease progression under standard-of-care treatment is still present for patients with CKD. In contrast to the above, several outcome trials with SGLT-2 (sodium-glucose cotransporter-2) inhibitors and MRAs (mineralocorticoid receptor antagonists) clearly suggest that these agents, apart from nephroprotection, offer important cardioprotection in this population. This article discusses existing evidence on the effects of SGLT-2 inhibitors and MRAs on cardiovascular outcomes in patients with CKD that open new roads in cardiovascular protection of this heavily burdened population.

Finerenone - are we there yet with a non-steroidal mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease?

Introduction: Chronic kidney disease occurs in 40% of subjects with diabetes and increases the risk of cardiovascular death three-fold, compared to having diabetes alone. The non-steroidal mineralocorticoid receptor antagonist finerenone protects against chronic kidney disease in animal models.Areas covered: This evaluation is of a phase 3 trial of finerenone; Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease (FIDELIO-DKD). In FIDELIO-DKD, finerenone reduced the primary composite outcome of kidney failure, a sustained decrease of at least 40% in eGFR over four weeks, or death from renal causes, from 21.1% to 17.8%, with a good safety profile.Expert opinion: Finerenone is an effective mineralocorticoid receptor antagonist for the treatment of diabetic chronic kidney disease. Recently, glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporters 2 (SGLT-2) inhibitors have been added to the list of medicines for use in subjects with this condition. Although finerenone has a different mechanism of action to these medicines, it will need to be tested and shown to be effective in presence of these medicines in diabetic kidney disease, prior to widespread use.