Hyperkalemia Risk After Finerenone Initiation in Diabetic Kidney Disease with Elevated Baseline Potassium: A Multicenter Cohort Study

Background/Objectives: Finerenone improves cardiovascular and renal outcomes in diabetic kidney disease (DKD), but hyperkalemia remains a key safety concern. Patients with elevated baseline potassium levels (≥4.9 mEq/L) are largely excluded from clinical trials, and real-world data in this population are scarce. Methods: In this retrospective multicenter cohort study derived from the FINE-TURK cohort, adults with DKD who initiated finerenone with baseline potassium ≥ 4.9 mEq/L were included. The primary outcome was clinically significant hyperkalemia (K ≥ 5.5 mEq/L) within three months. Multivariable logistic regression analyses were used to identify associated factors, with multiple sensitivity analyses performed. Results: A total of 166 patients were included, of whom 47 (28.3%) had baseline potassium levels between 5.1 and 5.5 mEq/L. Of the 166 patients, 35 (21.1%) reached the primary outcome, and 10 (6%) patients had follow-up potassium ≥ 6.0 mEq/L. 126 (76.8%) patients required no intervention, 24 (14.6%) were initiated on potassium binders, and finerenone was discontinued in only 12 (7.3%) patients. Lower baseline estimated glomerular filtration rate, baseline urinary albumin, loop diuretic use and 20 mg finerenone dose were associated with the primary outcome. In contrast, baseline potassium was not associated with the primary outcome. Conclusions: In patients with DKD and elevated baseline potassium levels, finerenone initiation was associated with manageable rates of hyperkalemia. Our findings support the cautious use of finerenone in selected patients under close monitoring, as well as highlight the need for a multidimensional approach to hyperkalemia risk assessment.

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Journal
Journal of Clinical Medicine
Published
2026-07-23
DOI
https://doi.org/10.3390/jcm15155758
Primary Topic
Potassium and Related Disorders
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article
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article

Hyperkalemia Risk After Finerenone Initiation in Diabetic Kidney Disease with Elevated Baseline Potassium: A Multicenter Cohort Study

Alper Tuna Güven, Betül Doğantekin, Mehmet Emin Demir, İlyas Öztürk et al.
Journal of Clinical Medicine
Potassium and Related Disorders
article

Hyperkalemia Risk After Finerenone Initiation in Diabetic Kidney Disease with Elevated Baseline Potassium: A Multicenter Cohort Study

Alper Tuna Güven, Betül Doğantekin, Mehmet Emin Demir, İlyas Öztürk, Meral Meşe, S Koyuncu, Ali İLTER, Murat Altunok, Tülin Akagün, Ezgi Avanaz, Arda Erdut, Ayça İnci, Bülent Demirelli, Sinan Kazan, Eda Altun, Serpil Müge Değer, Ahmet Ziya Şahin, Mustafa DEMİR, Murat Duranay, Serap Yadigar, Murat Özdede, Beril Akman, Mehmet Horoz, Mine Şebnem Karakan, Mehmet Batmazoğlu, Serkan Feyyaz Yalın, Serhan Tuğlular, Suat Akgür, Bahar Gürlek Demirci, Atila Altuntaş, Merve Tekinyıldız, Mehmet Sezen, Serkan Bakırdöğen, Mehmet Mert, Mahmut Başar Aykent, Mehmet Fethullah AYDIN, Ekrem Kara, Meral Mert, Belda Dursun, Pınar Özdemir, Mahmud İslam, Di̇lek Torun, Elif Yıldırım Ayaz, Cüneyt Akgöl, Serdar Kahvecioğlu, Fatma Yılmaz Aydın, Asil Demirezen, Siren Sezer, Felemez Arslan, Mukadder Ayşe Bilgiç, İsmail Baloğlu, Emre Aydın, Erkan Şengül, B. Ozcan, Sena Ulu, Elif Arı Bakır, Hülya Çolak, Beyza Doğan, Funda Sarı, Asena Serap Yalcinkaya, İlker Atay, Ahmet Ekmekci, Fatih Yilmaz, Gülşah Keskin, Öznur Baykal, Simge Bardak Demir, Bartu Ediz, Ergün Parmaksız, Ulver Derici, Hazal Melike Yavuz Umut, Mehmet Polat, Mehmet Deniz Aylı, Necmi Eren, Huseyin Celik, Süleyman Karaköse, Üstün Yılmaz, Zeki Aydın, Ramazan Sarı, Sibel Yücel Koçak, Kültigin Türkmen, Ebru Gok Oguz, Mustafa Arıcı, Suat Ünver
article en

Abstract

Background/Objectives: Finerenone improves cardiovascular and renal outcomes in diabetic kidney disease (DKD), but hyperkalemia remains a key safety concern. Patients with elevated baseline potassium levels (≥4.9 mEq/L) are largely excluded from clinical trials, and real-world data in this population are scarce. Methods: In this retrospective multicenter cohort study derived from the FINE-TURK cohort, adults with DKD who initiated finerenone with baseline potassium ≥ 4.9 mEq/L were included. The primary outcome was clinically significant hyperkalemia (K ≥ 5.5 mEq/L) within three months. Multivariable logistic regression analyses were used to identify associated factors, with multiple sensitivity analyses performed. Results: A total of 166 patients were included, of whom 47 (28.3%) had baseline potassium levels between 5.1 and 5.5 mEq/L. Of the 166 patients, 35 (21.1%) reached the primary outcome, and 10 (6%) patients had follow-up potassium ≥ 6.0 mEq/L. 126 (76.8%) patients required no intervention, 24 (14.6%) were initiated on potassium binders, and finerenone was discontinued in only 12 (7.3%) patients. Lower baseline estimated glomerular filtration rate, baseline urinary albumin, loop diuretic use and 20 mg finerenone dose were associated with the primary outcome. In contrast, baseline potassium was not associated with the primary outcome. Conclusions: In patients with DKD and elevated baseline potassium levels, finerenone initiation was associated with manageable rates of hyperkalemia. Our findings support the cautious use of finerenone in selected patients under close monitoring, as well as highlight the need for a multidimensional approach to hyperkalemia risk assessment.

Journal of Clinical MedicineVol. 15(15)
Sakarya University (TR), Çanakkale Onsekiz Mart Üniversitesi (TR), Dicle University (TR), Bahçeşehir University (TR), Ministry of Health (TR), Izmir University (TR), Giresun University (TR), Ankara University (TR), Recep Tayyip Erdoğan University (TR), University of Health Science (KH), Karabük University (TR), Süleyman Demirel Üniversitesi (TR), Başkent University (TR), Bursa Technical University (TR), Dokuz Eylül University (TR), Akdeniz University (TR), Konya Food and Agriculture University (TR), State Hospital (GB), Kütahya Dumlupınar Üniversitesi (TR), Turkish Society of Hematology (TR), Ankara Atatürk Eğitim ve Araştırma Hastanesi (TR), Memorial Ankara Hospital (TR), Uni Research (Norway) (NO), Dr Lütfi Kırdar Kartal Eğitim ve Araştırma Hastanesi (TR), Necmettin Erbakan University (TR), Ankara Numune Eğitim ve Araştırma Hastanesi (TR), Antalya Eğitim ve Araştırma Hastanesi (TR), Suleyman Demirel University (KZ), Konya Eğitim ve Araştırma Hastanesi (TR), Bakırköy Dr.Sadi Konuk Eğitim ve Araştırma Hastanesi (TR), Education Training And Research (US), Haydarpaşa Numune Eğitim ve Araştırma Hastanesi (TR), Kayseri Eğitim ve Araştırma Hastanesi (TR), Sağlık Bilimleri Üniversitesi (TR), Universidad CES (CO), Denizli Devlet Hastanesi (TR), Turku City Hospital (FI), Ankara Yıldırım Beyazıt University (TR), Şişli Etfal Eğitim ve Araştırma Hastanesi (TR), Antalya IVF (TR), S.B.Ü. Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi (TR), Afyonkarahisar Sağlık Bilimleri Üniversitesi, Kahramanmaraş Sütçü İmam University (TR), Pamukkale University (TR), Adana Science and Technology University (TR), Kocaeli Üniversitesi (TR), Afyon Kocatepe University (TR), Hacettepe University (TR), Marmara University (TR), University of Health Sciences Antigua (AG), Gazi University (TR)
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Potassium and Related Disorders
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