ESC heart failure · 2026
Finerenone versus Steroidal MRAs in Type 2 Diabetes and Chronic Kidney Disease without Prior Heart Failure.
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Kishimori Takefumi, Kato Takao, Iwasaki Yoshihiro, Shimada Takenobu, Tani Akira, Yamaji Ryosuke, Koike Jumpei, Matsumoto Takehiro, Yagi Takafumi, Okada Masaharu
Аннотация
AIMS: Type 2 diabetes (T2D) and chronic kidney disease (CKD) markedly increase the risk of heart failure (HF) and death. While finerenone improves outcomes in clinical trials, real-world evidence and direct comparisons with steroidal mineralocorticoid receptor antagonists (MRAs) are limited. We evaluated finerenone versus steroidal MRAs (spironolactone and eplerenone) in patients without prior HF.
METHODS: Using the TriNetX platform, we conducted a retrospective multi-center observational study. We identified patients aged ≥18 years with T2D and CKD without prior HF and ischemic heart disease, who initiated MRAs after receiving a sodium-glucose co-transporter 2 (SGLT2) inhibitor as first-line therapy between 2021 and 2024 (N=3,680). Of these, 724 initiated finerenone and 1,542 initiated a steroidal MRA. After propensity score matching, each group included 551 patients. The primary outcome was all-cause death during the 18-month follow-up period; the secondary outcome was new-onset HF and renal outcome (a composite of end-stage renal disease and dialysis).
RESULTS: Over 18-month, finerenone initiation was associated with lower incidence rates of all-cause death (2.1 vs 4.5 events/100 person-years; incidence rate difference, -2.41; 95% CI, -4.38 to -0.44) and new-onset HF (6.5 vs 12.9; -6.38; 95% CI, -9.75 to -3.02), whereas no significant difference was observed for the renal outcome (8.3 vs 9.1; -0.81; 95% CI, -3.99 to 2.37).
CONCLUSIONS: Finerenone was associated with a lower 18-month risk of all-cause death compared with steroidal MRAs in patients aged ≥18 years with T2D and CKD without prior HF, who received an SGLT2 inhibitor as first-line therapy; however, residual confounding cannot be excluded, and these findings should be considered hypothesis-generating.
METHODS: Using the TriNetX platform, we conducted a retrospective multi-center observational study. We identified patients aged ≥18 years with T2D and CKD without prior HF and ischemic heart disease, who initiated MRAs after receiving a sodium-glucose co-transporter 2 (SGLT2) inhibitor as first-line therapy between 2021 and 2024 (N=3,680). Of these, 724 initiated finerenone and 1,542 initiated a steroidal MRA. After propensity score matching, each group included 551 patients. The primary outcome was all-cause death during the 18-month follow-up period; the secondary outcome was new-onset HF and renal outcome (a composite of end-stage renal disease and dialysis).
RESULTS: Over 18-month, finerenone initiation was associated with lower incidence rates of all-cause death (2.1 vs 4.5 events/100 person-years; incidence rate difference, -2.41; 95% CI, -4.38 to -0.44) and new-onset HF (6.5 vs 12.9; -6.38; 95% CI, -9.75 to -3.02), whereas no significant difference was observed for the renal outcome (8.3 vs 9.1; -0.81; 95% CI, -3.99 to 2.37).
CONCLUSIONS: Finerenone was associated with a lower 18-month risk of all-cause death compared with steroidal MRAs in patients aged ≥18 years with T2D and CKD without prior HF, who received an SGLT2 inhibitor as first-line therapy; however, residual confounding cannot be excluded, and these findings should be considered hypothesis-generating.