Triple therapy of RAS inhibitors, dapagliflozin, and finerenone in diabetic kidney disease patients with nephrotic-range proteinuria: a real-world study

Patients with diabetic kidney disease (DKD) and nephrotic-range proteinuria (NRP) face an extremely high cardiorenal risk. Renin-angiotensin system (RAS) inhibitors, sodium-glucose cotransporter-2 (SGLT2) inhibitors, and the non-steroidal mineralocorticoid receptor (ns-MR) antagonist finerenone are the cornerstone therapies for DKD. However, real-world data on the efficacy and safety of triple therapy with RAS inhibitors, SGLT2 inhibitors, and finerenone in DKD patients with NRP remain scarce. This retrospective study included adult DKD patients with NRP treated with triple therapy. Clinical parameters assessed included proteinuria, renal function, serum albumin, serum potassium, and adverse events during follow-up. Twenty DKD patients with NRP (mean age 61 ± 12 years; female/male 8/12) were included. Baseline characteristics were as follows: UPCR 5275.53 [3838.11, 8976.90] mg/g, UACR 4144.54 [3077.21, 6070.61] mg/g, eGFR 48.51 ± 21.31 ml/min/1.73 m², serum potassium 4.11 ± 0.53 mmol/L. Compared to baseline, UPCR decreased by 55.49% (P < 0.001), UACR decreased by 59.66% (P < 0.001), and eGFR declined by 4.03 mL/min/1.73 m² at month 12 (P = 0.170). Serum albumin increased from 34.5 ± 6.9 g/L to 38.6 ± 4.9 g/L (P = 0.061) at month 12. No serious adverse events, such as hyperkalemia (> 5.5 mmol/L), were observed. This real-world study shows the efficacy of triple therapy with RAS inhibitors, dapagliflozin, and finerenone in DKD patients with NRP, along with a favorable safety profile.