Letter to the Editor: Finerenone and proteinuria in diabetic kidney disease.

Most patients with diabetic kidney disease (DKD) suffer from proteinuria. Finerenone, a novel nonsteroidal mineralocorticoid receptor antagonist acts as anti-inflammatory factor reducing the kidney inflammation and fibrotic pathways, which are overactive in patients with advanced proteinuria. The study by Pasari et al, published in the recent issue of the World Journal of Nephrology, correlated the greater reduction of albuminuria with the higher baseline albuminuria using finerenone. However, heterogeneity, disproportion and variability in response using finerenone for the reduction of proteinuria has been observed. Patients with persistent proteinuria despite the optimal renin-angiotensin-aldosterone system blockage, sodium-glucose co-transporter -2 inhibitors and finerenone, remain at high risk for renal and cardiovascular events. More factors including the novel functions of histone lactylation possibly are involved in the deterioration of albuminuria in DKD. It may need combined and intensive therapy with an additional healthy lifestyle. More pharmacogenomic trials, proteomic analyses in long-term real-world cohorts need to clarify the pathogenetic mechanisms related to proteinuria in DKD.