Comparative Cardiorenal Efficacy and Safety of Finerenone, SGLT2 Inhibitors, Semaglutide and Their Combination in Diabetic Kidney Disease

AIM: To compare the cardiorenal efficacy and safety of finerenone, sodium-glucose cotransporter 2 inhibitors (SGLT2i), semaglutide and finerenone-SGLT2i combination therapy in diabetic kidney disease (DKD). MATERIALS AND METHODS: PubMed, Embase and CENTRAL were searched through July 9, 2026 for randomized trials involving adults with Type 2 diabetes and DKD. A frequentist network meta-analysis estimated risk ratios (RRs) with 95% confidence intervals (CIs) for cardiorenal and safety outcomes. RESULTS: Ten randomized datasets involving 37 923 participants were included. Compared with control, dapagliflozin, canagliflozin, finerenone and semaglutide reduced both cardiovascular composite events and composite kidney outcomes; sotagliflozin reduced cardiovascular composite events, and empagliflozin reduced composite kidney outcomes. SGLT2i showed the broadest overall pattern of benefit across cardiorenal outcomes. Dapagliflozin was associated with a lower risk of the composite kidney outcome than semaglutide (RR 0.71, 95% CI: 0.53-0.94), while most other efficacy comparisons between active monotherapies were not statistically significant. Finerenone increased hyperkalaemia (RR 2.03, 95% CI: 1.82-2.26) and treatment discontinuation due to adverse events (RR 1.18, 95% CI: 1.02-1.35). Finerenone plus empagliflozin was associated with a higher risk of hyperkalaemia than empagliflozin alone (RR 2.48, 95% CI: 1.22-5.06). CONCLUSIONS: SGLT2i showed the broadest cardiorenal benefits, while finerenone and semaglutide provided additional protection across selected outcomes. Finerenone increased hyperkalaemia and treatment discontinuation. The efficacy of finerenone-SGLT2i combination therapy requires further investigation.