Efficacy and safety of finerenone in patients with chronic kidney disease and type 2 diabetes by diuretic use: A FIDELITY analysis

Aims This post hoc analysis aimed to assess the efficacy and safety of the non-steroidal mineralocorticoid receptor antagonist finerenone by baseline diuretic use in FIDELITY, a pre-specified pooled analysis of the phase III trials FIDELIO-DKD and FIGARO-DKD. Methods and results Eligible patients with type 2 diabetes (T2D) and chronic kidney disease (CKD; urine albumin-to-creatinine ratio [UACR] >= 30-<300 mg/g and estimated glomerular filtration rate [eGFR] >= 25-<= 90 ml/min/1.73 m(2), or UACR >= 300-<= 5000 mg/g and eGFR >= 25 ml/min/1.73 m(2)) were randomized 1:1 to finerenone or placebo. Patients were analysed by baseline diuretic use (yes/no) and type of diuretic (loop or thiazide). Key efficacy outcomes included a cardiovascular composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for heart failure) and a kidney composite (kidney failure, sustained >= 57% decrease in eGFR, or kidney-related death). Out of 12 990 patients, 51.6% were taking diuretics at baseline (21.6% loop; 24.2% thiazide diuretics). Finerenone reduced the risk of cardiovascular and kidney composite outcomes versus placebo; diuretic use did not modify this effect on the cardiovascular (p-interaction = 0.94) or kidney outcomes (p-interaction = 0.55). Hyperkalaemia incidences were similar between finerenone subgroups irrespective of diuretic use and lower with placebo versus finerenone (with diuretics: finerenone 13.7% vs. placebo 5.7%; without diuretics: 14.3% vs. 8.3%). The incidence of hyperkalaemia leading to hospitalization or study drug discontinuation was low across treatment groups irrespective of diuretic use. Conclusion This analysis showed that the efficacy and safety of finerenone in patients with CKD and T2D was not modified by baseline diuretic use.