The appropriateness of finerenone initiation, dosing, and outcomes in diabetic kidney disease: data from real world practice

Finerenone has been shown to improve renal outcomes in patients with diabetic kidney disease. Appropriate use according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline criteria are essential to maximize its clinical benefit. However, the initiation and monitoring requirements are complex, making full adherence challenging in real-world practice, especially in resource-limited settings. This retrospective study was conducted at Somdech Phra Pinklao Hospital, Bangkok, Thailand, and included all adult patients who received finerenone between March 2023 and September 2025. The primary outcome was the proportion of patients who fulfilled guideline-based indications and were prescribed the appropriate starting dose of finerenone according to KDIGO recommendations. A total of 57 patients were included (mean age 70.3 ± 12.9 years). Only 24 (42.1%) fulfilled all KDIGO-based criteria for finerenone initiation and were prescribed the appropriate starting dose. The criterion least frequently fulfilled was the use of a maximally tolerated renin–angiotensin system inhibitor (RASi), achieved in only 32 patients (56.1%). In the subgroup analysis, the annual rate of estimated glomerular filtration rate (eGFR; mL/min/1.73 m²) decline was comparable between the guideline-adherent and non-adherent groups (-6.69 ± 15.32 vs. -5.54 ± 8.41; p = 0.762), and the proportion of patients with albuminuria/proteinuria improvement was also similar (20.8% vs. 42.4%; p = 0.088). A significant proportion of finerenone prescriptions did not adhere to guideline recommendations. These findings highlight the need to strengthen adherence to guideline-based prescribing and monitoring. While our results suggest that finerenone maintains renal efficacy and safety in clinical practice despite suboptimal guideline adherence, further larger clinical studies are warranted to confirm these findings.