A New Horizon of Cardiorenal Protection through Inhibition of Inflammation and Fibrosis in Diabetic Kidney Disease: Clinical Significance of Finerenone

Non-steroidal mineralocorticoid receptor antagonists (NS-MRAs) have emerged as a novel therapeutic class while minimizing the endocrine adverse effects associated with steroidal MRAs, such as spironolactone and eplerenone. Finerenone, the first clinically approved NS-MRA, exhibits high receptor selectivity, minimal off-target hormonal activity, and exerts potent anti-inflammatory and antifibrotic actions that complement renin-angiotensin system inhibition and sodium-glucose cotransporter-2 (SGLT2) inhibitor therapy. The pivotal FIDELIO-DKD and FIGARO-DKD trials demonstrated clinically meaningful reductions in kidney disease progression and cardiovascular composite outcomes in patients with type 2 diabetes and albuminuric chronic kidney disease (urine albumin-creatinine ratio ≥ 30 mg/g), the pooled FIDELITY analysis confirmed consistent cardiorenal benefits across diverse risk strata. Hyperkalaemia remains a principal safety concern and requires potassium monitoring and dose adjustments in routine practice. Emerging short-term data on albuminuria suggest the additional benefits of concomitant SGLT2 inhibitor therapy, although definitive outcome evidence for combination strategies is still evolving. Ongoing clinical programs further extend the therapeutic scope of finerenone to heart failure with preserved ejection fraction, non-diabetic chronic kidney disease, and type 1 diabetes. Collectively, NS-MRAs provide a mechanistically distinct strategy targeting inflammation and fibrosis and represent an important therapeutic advance in integrated cardiorenal-metabolic risk reduction.