Comparative efficacy and safety of finerenone in diabetic kidney disease: a meta-analysis of Asian and non-Asian populations

BACKGROUND & OBJECTIVE: Diabetic kidney disease (DKD) is a major global burden, especially in Asia. This study aimed to evaluate the efficacy and safety of finerenone in diabetic kidney disease, comparing outcomes between Asian and non-Asian populations through a systematic review and meta-analysis. METHODS: A systematic search was conducted across PubMed, Cochrane Library, ClinicalTrials.gov, Google Scholar, and the Undermind AI platform from inception through March 2025. Studies included randomized controlled trials (RCTs) and subgroup analyses that evaluated finerenone in DKD patients. Primary outcomes included a reduction in the urinary albumin-to-creatinine ratio (UACR) and a decline in the estimated glomerular filtration rate (eGFR) of ≥40%. Secondary outcomes included cardiovascular events, mortality due to kidney failure, hyperkalemia (serum potassium >5.0 mmol/L), treatment discontinuation, hospitalization, and adverse event-related mortality. Risk ratios (RRs) and mean differences (MDs) were pooled using a random-effects model, and subgroup analyses were performed by ethnicity. RESULTS: Five eligible studies, comprising 8,763 participants, were included in this analysis. Finerenone significantly reduced UACR compared with placebo (MD = -0.38, 95% CI -0.42 to -0.35; p < 0.001), with consistent effects across Asian and non-Asian populations (subgroup p = 0.28). It also significantly reduced the risk of eGFR decline ≥40% (MD = -0.24 [-0.40, -0.09]; p = 0.002), with a greater benefit in the Asian subgroup (subgroup p = 0.03). Cardiovascular event risk was also reduced (RR = 0.85 [0.77-0.95]; p = 0.004), while mortality due to kidney failure showed a non-significant reduction (RR = 0.83 [0.64-1.07]; p = 0.15). Hyperkalemia risk was higher with finerenone (RR = 1.73, 95% CI 1.39-2.14), whereas adverse event-related mortality was lower (RR = 0.65, 95% CI 0.46-0.91). CONCLUSION: Finerenone provides robust renoprotective and cardioprotective effects in DKD, with broadly consistent efficacy across Asian and non-Asian populations. A greater renal benefit was observed in Asians for eGFR decline ≥40%, though this requires cautious interpretation. Hyperkalemia risk was increased but largely manageable. These findings support integration into DKD therapy and highlight the need for ethnically inclusive, long-term, real-world trials. CLINICAL TRIAL NUMBER: Not applicable.