Nonsteroidal mineralocorticoid receptor antagonist in diabetic kidney disease: mechanistic insights and clinical integration

Nonsteroidal mineralocorticoid receptor antagonists (ns-MRA) have emerged as a key therapeutic option for patients with type 2 diabetes and chronic kidney disease, addressing the unmet cardiorenal risk that persists under standard renin-angiotensin system therapy. Finerenone, the most extensively studied ns-MRA, has demonstrated significant reductions in kidney and cardiovascular outcomes across a broad spectrum of CKD severity, with a favorable safety profile. Recent guideline recommendations endorse ns-MRAs in patients with persistent albuminuria despite optimized standard therapy. Moreover, combination strategies with sodium-glucose cotransporter 2 inhibitors show additive benefits, supporting a multi-targeted treatment approach. This review summarizes the pathophysiological rationale, clinical evidence, safety considerations, and combination strategies involving ns-MRAs in contemporary diabetic kidney disease management.