Effect of finerenone on cardiovascular events in kidney disease and/or diabetes: a meta analysis of randomized control trials

Pharmacology; ii. Cardiovascular Disease and iii. Systematic Review and Meta-analysis. Effectiveness and safety of chronic diuretic use in older adults: an umbrella review of recently published systematic reviews and meta-analyses of randomized-controlled trials

BACKGROUND

Healthcare providers should balance the potential risks and benefits of chronic diuretic use, particularly in older adults, as with age, diuretic benefits may decline and risks increase. A comprehensive synthesis and critical evaluation of the available evidence on chronic diuretic treatment effects is currently lacking.

METHODS

We conducted an umbrella review of systematic reviews and meta-analyses published since 2018 on health outcomes associated with diuretic use in randomized-controlled trials (RCTs). We conducted random-effects meta-analysis for pooled effect estimates and narratively summarized data that could not be pooled.

RESULTS

We included 741 effect estimations from 117 systematic reviews (SRs) on 1566 RCTs in individuals aged 62 ± 6 years. Of our 33 meta-analyses, 11 provided convincing, high-quality evidence: finerenone reduced the risk of cardiovascular (CV) mortality and end-stage kidney disease in individuals with chronic kidney disease (CKD) and/or type 2 diabetes (T2D). Torasemide reduced the risk of heart failure-related hospitalization (HFH) more than furosemide in individuals with HF. Thiazides reduced CV events in individuals with hypertension. Mineralocorticoid receptor antagonists (MRAs) reduced HFH, but also increased hyperkalemia risk in individuals with HF. MRAs also reduced the risk of atrial fibrillation in those with HF or CVD, and reduced HFH, major adverse cardiovascular events (MACEs), > 40% eGFR decrease, and composite kidney outcomes in individuals with CKD and/or T2D. Lower quality evidence suggests that in older (≥ 65 years), but not in younger adults, diuretics may reduce CV mortality, but also increase adverse event (AE) risk.

CONCLUSIONS

Our umbrella review offers a comprehensive and up-to-date evaluation of the benefits and harms of diuretics. However, further research is needed to establish their efficacy and safety in populations commonly seen in clinical practice, especially older adults living with multimorbidity and frailty.

Use of finerenone in patients with chronic kidney disease at high risk of heart failure

Treatment of symptomatic/advanced heart failure (HF) in patients who also have chronic kidney disease (CKD) and type 2 diabetes (T2D) may include a steroidal mineralocorticoid receptor antagonist (MRA). However, patients with CKD and T2D who are at high risk of developing HF may benefit from taking the nonsteroidal MRA finerenone. Results from phase 3 placebo-controlled trials of finerenone in patients with CKD associated with T2D showed that finerenone (plus a renin-angiotensin-aldosterone system inhibitor) reduced the risk of new-onset HF, improved other HF outcomes, and caused a significant slowing of CKD progression. Those who work in cardiology need to be aware of the HF risk-reduction effects of finerenone in patients with CKD and T2D. In this review, we provide a rationale for finerenone use in cardiology based on the available finerenone clinical trial data and from the perspective of a cardiologist who prescribes finerenone to patients who have comorbid CKD and T2D.

Role and application prospective of non-steroidal MRA in the treatment of diabetic kidney disease

Chronic kidney disease (CKD) has diverse etiologies and complex pathogenesis, and is prone to recurrent episodes and prolonged illness. In recent years, the prevalence of CKD has been increasing year by year, and the global prevalence in the general population has reached 14.3%. Diabetic kidney disease (DKD) is a common complication of diabetes mellitus (DM), and about 20-40% of DM patients have combined DKD, which is also the main cause of CKD and end-stage renal disease (ESRD). DM catalyzes CKD in approximately 30-50% of global cases, affecting around 285 million individuals. It primarily triggers diabetic nephropathy (DN), the leading cause of end-stage renal disease worldwide. Research indicates that activation of the mineralocorticoid receptor (MR) plays a role in the onset and progression of DKD. Counteracting MR overactivation offers antioxidative, anti-inflammatory, and anti-fibrotic benefits, thereby ameliorating target organ damage. MR antagonists (MRAs) such as spironolactone and eplerenone have been validated for renal protection. However, their clinical application is hindered by adverse effects including hyperkalemia, gynecomastia in males, erectile dysfunction, and menstrual irregularities in females. Finerenone, a novel non-steroidal MRA, exhibits a unique mechanism of action, binding to MR and inhibiting the recruitment of transcription co-factors involved in gene expression, effectively slowing the progression of diabetic nephropathy (DN). In addition, finerenone demonstrates improved safety and efficacy in treating heart failure and chronic kidney disease. It also plays a significant role in the management of atrial fibrillation and myocardial infarction. This article reviews recent studies on finerenone, summarizing its mechanism of action in treating DN, evidence from clinical trials, adverse reactions, combined use with other inhibitors, and future prospective, aiming to provide insights for the prevention and treatment of DN.

Cardiovascular Efficacy and Safety of Finerenone: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, has emerged as a novel therapeutic option for the management of patients with diabetes, chronic kidney disease, or heart failure. We seek to summarize the evidence on the drug's effectiveness regarding cardiovascular (CV) outcomes.

METHODS

We conducted a literature search of Pubmed, Cochrane CENTRAL, Embase, and ClinicalTrials.gov from inception to September 2024. Trials exploring the effects of finerenone on CV outcomes were extracted and analyzed. The results of pooled analyses were presented as risk ratios (RRs) with 95% confidence intervals (CIs).

RESULTS

A total of eight trials, incorporating 21 200 patients, were included. The pooled analysis demonstrated a significant reduction in all-cause death (RR 0.92, 95% CI: 0.85-0.99), major adverse CV events (RR 0.85, 95% CI: 0.81-0.90), heart failure-related hospitalizations or unplanned hospital visits (RR 0.82, 95% CI: 0.76-0.87) with finerenone administration compared to control. Finerenone use was associated with a trend of reduced risk of CV death without reaching statistical significance (RR 0.90, 95% CI: 0.81-1.00). The risk of myocardial infarction (RR 0.91, 95% CI: 0.74-1.12), adverse events (RR 0.96, 95% CI: 0.89-1.03), adverse events leading to discontinuation (RR 1.06, 95% CI: 0.96-1.17) remained comparable across both groups. However, an increased risk of hyperkalemia (RR 2.07, 95% CI: 1.88-2.27) was observed with finerenone therapy compared to the control group.

CONCLUSION

Finerenone administration was associated with improved CV outcomes in the CV-renmetabolic conditions compared to the control group.

Efficacy of Mineralocorticoid Receptor Antagonists on Kidney and Cardiovascular Outcomes in Patients With Chronic Kidney Disease: An Umbrella Review

Rationale & Objective

To comprehensively summarize the efficacy of mineralocorticoid receptor antagonists (MRAs) to improve kidney and cardiovascular (CV) outcomes in patients with chronic kidney disease (CKD).

Study Design

Relevant studies were identified from Medline and Scopus databases from their inception up to August 2023.

Setting & Study Populations

Patients with nondialysis or dialysis CKD.

Selection Criteria for Studies

Systematic reviews and meta-analyses (SR-MAs) of randomized controlled trials (RCTs) that investigated the efficacy of MRAs on kidney and CV outcomes in patients with nondialysis or dialysis CKD were included in this study.

Data Extraction

Characteristics of studies and participants, and treatment effects were extracted.

Analytic Approach

Efficacy of MRAs was qualitatively summarized according to types of patients and MRAs.

Results

Forty SR-MAs were included. When compared with placebo/usual care, steroidal MRAs (sMRAs) provided significant benefit in decreasing all-cause (pooled RRs of 0.38 [0.22-0.65] to 0.87 [0.77-0.98]) and CV mortality (pooled RRs of 0.34 [0.15-0.75] to 0.46 [0.28-0.76]) only in patients treated with dialysis, when compared with placebo. Nonsteroidal MRAs (nsMRAs) significantly lowered composite CV events in both nondialysis CKD (pooled RRs of 0.86 [0.79-0.94] to 0.92 [0.85-0.99]) and patients with diabetic kidney disease (DKD) (pooled RRs of 0.86 [0.78-0.95] to 0.88 [0.81-0.96]). In addition, nsMRAs showed significant benefit in reducing composite kidney outcomes in patients with either nondialysis CKD or DKD when compared with placebo. However, this efficacy was lower than sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with DKD. Moreover, both sMRAs and nsMRAs significantly increased the risk of hyperkalemia in patients with nondialysis CKD and DKD.

Limitations

The comparison between nsMRAs and SGLT2i is based on network meta-analyses. Consequently, additional head-to-head RCTs are necessary to confirm the advantages of SGLT2i over nsMRAs.

Conclusions

sMRAs offer benefits in reducing all-cause and cardiovascular mortality and composite CV events in patients treated with dialysis. nsMRAs improve kidney outcomes in patients with nondialysis CKD and DKD but increase hyperkalemia risk.

The significance of finerenone as a novel therapeutic option in diabetic kidney disease: a scoping review with emphasis on cardiorenal outcomes of the finerenone phase 3 trials

This scoping review prepared by endocrinology and nephrology experts aimed to address the significance of finerenone, as a novel therapeutic option, in diabetic kidney disease (DKD), based on the biological prospect of cardiorenal benefit due to non-steroidal mineralocorticoid receptor antagonist (MRA) properties, and the recent evidence from the finerenone phase 3 program clinical trials. The importance of finerenone in slowing DKD progression was critically reviewed in relation to the role of MR overactivation in the pathogenesis of cardiorenal disease and unmet needs in the current practice patterns. The efficacy and safety outcomes of finerenone phase III study program including FIDELIO-DKD, FIGARO-DKD and FIDELITY were presented. Specifically, perspectives on inclusion of patients with preserved estimated glomerular filtration rate (eGFR) or high albuminuria, concomitant use of sodium-glucose co-transporter-2 inhibitor (SGLT2i) or glucagon-like peptide 1 receptor agonist (GLP-1 RA), baseline glycated hemoglobin (HbA1c) level and insulin treatment, clinically meaningful heart failure outcomes and treatment-induced hyperkalemia were addressed. Finerenone has emerged as a new therapeutic agent that slows DKD progression, reduces albuminuria and risk of cardiovascular complications, regardless of the baseline HbA1c levels and concomitant treatments (SGLT2i, GLP-1 RA, or insulin) and with a favorable benefit-risk profile. The evolving data on the benefit of SGLT2is and non-steroidal MRAs in slowing or reducing cardiorenal risk seem to provide the opportunity to use these pillars of therapy in the management of DKD, after a long-period of treatment scarcity in this field. Along with recognition of the albuminuria as a powerful marker to detect those patients at high risk of cardiorenal disease, these important developments would likely to impact standard-of-care options in the setting of DKD.

The role of a novel mineralocorticoid receptor antagonist, finerenone, in chronic kidney disease: mechanisms and clinical advances

BACKGROUND

Chronic kidney disease (CKD) poses a significant health risk in contemporary society. Current CKD treatments primarily involve renin-angiotensin-aldosterone system inhibitors and mineralocorticoid receptor antagonists, albeit associated with hyperkalemia risks. A novel selective mineralocorticoid receptor antagonist, finerenone, offers a promising, safer alternative for CKD therapy. This review comprehensively assesses the role and efficacy of finerenone in CKD treatment by analyzing clinical and animal studies. Emerging evidence consistently supports finerenone's ability to effectively slow the progression of CKD. By targeting the mineralocorticoid receptor, finerenone not only mitigates renal damage but also exhibits a favorable safety profile, minimizing hyperkalemia concerns.

CONCLUSION

Finerenone emerges as a valuable addition to CKD therapy, demonstrating potential benefits in delaying CKD progression while minimizing side effects. Nevertheless, further clinical trials are necessary to provide a comprehensive understanding of its safety and efficacy.