Kidney Outcomes With GLP ‐1 Receptor Agonists and Tirzepatide Versus Finerenone in Type 2 Diabetes and Chronic Kidney Disease: A Real‐World Cohort Study

ABSTRACT Aim To compare kidney outcomes after GLP‐1 receptor agonists (RA) or tirzepatide (GLP‐1/GIP RAs) versus finerenone initiation in adults with Type 2 diabetes (T2D) and moderate chronic kidney disease (CKD). Methods In a retrospective TriNetX global network study (July 2021–November 2025), adults with T2D and CKD stages 3–4 initiating GLP‐1/GIP RAs or finerenone were 1:1 propensity‐score matched and followed ≤ 2.5 years. The primary endpoint was a composite of ESKD, Stage 5 CKD, or dialysis initiation. Secondary analyses compared annual total (0–2.5 years) and chronic (0.5–2.5 years) estimated glomerular filtration rate (eGFR) slopes. Sensitivity analyses included positive/negative controls, extended follow‐up, and stratification by age, sex, baseline kidney function, glycated haemoglobin A1c, BMI, specific GLP‐1/GIP RA, and baseline medications. Results Among 4554 individuals (43.3% women, mean age 70.7 years, mean eGFR 39.4 mL/min/1.73 m 2 ), the primary endpoint occurred in 110 (4.8%) GLP‐1/GIP RAs and 136 (6.0%) finerenone initiators (hazard ratio: 0.71 [95% CI: 0.55–0.91]; 2.5‐year absolute risk difference: −1.14% [−2.45 to 0.17]). Between‐group differences in total and chronic eGFR slope with GLP‐1/GIP RA versus finerenone were 1.04 mL/min/1.73 m 2 /year [95% CI: 0.32 to 1.75] and −0.08 mL/min/1.73 m 2 /year [95% CI, −1.27 to 1.12], respectively. Sensitivity analyses were consistent. Baseline albuminuria data were missing for most participants. Conclusions In a real‐world cohort, GLP‐1/GIP RAs versus finerenone initiation was associated with a lower relative hazard of adverse kidney outcomes, without evidence of a difference in absolute risk. This was accompanied by total, but not chronic, eGFR slope mitigation. Residual confounding from under‐sampled albuminuria is possible, and findings should be interpreted within this specific matched population.