Comparative effectiveness of finerenone versus steroidal mineralocorticoid receptor antagonists on sepsis-induced cardiomyopathy in patients with diabetic kidney disease: a real-world cohort study

Background Sepsis-induced cardiomyopathy (SICM) is a common but underrecognized complication of sepsis and is associated with adverse short- and long-term outcomes. Patients with diabetic kidney disease (DKD) are particularly vulnerable to sepsis-related cardiac dysfunction, potentially due to chronic inflammation and heightened mineralocorticoid receptor (MR) activation. Whether non-steroidal MRAs are associated with a lower risk of SICM compared with steroidal MRAs remains unknown. Methods Using the TriNetX federated electronic health record network, we conducted a retrospective cohort study of adults with DKD and sepsis between 2021 and 2025. Patients initiating finerenone were compared with those initiating steroidal MRAs. Propensity score matching (1:1) was performed to balance baseline characteristics. The primary outcome was SICM, defined by heart failure, cardiogenic shock, pulmonary edema, or left ventricular ejection fraction ≤50%. Secondary outcomes included all-cause mortality and surrogate markers of myocardial injury. Cox proportional hazards models were used to estimate hazard ratios (HRs). Results After matching, 1,378 patients were included in each group. Finerenone use was associated with a significantly lower risk of SICM compared with steroidal MRAs (3.3% vs 5.2%; HR 0.59, 95% CI 0.40–0.87). Finerenone was also associated with lower all-cause mortality (HR 0.45, 95% CI 0.31–0.65) and a reduced risk of surrogate myocardial injury outcomes (HR 0.48, 95% CI 0.25–0.90). Results were generally directionally similar across several subgroup analyses, although the association was attenuated among patients not receiving SGLT2 inhibitors. Conclusion In this real-world cohort of patients with DKD and sepsis, finerenone use was associated with a lower observed risk of clinically recognized SICM compared with steroidal MRAs. A lower all-cause mortality rate was also observed; however, given the magnitude of this association and the observational design, this finding should be interpreted cautiously and may reflect residual confounding or treatment-selection bias. These findings are hypothesis-generating and require confirmation in prospective studies.