A comparative real-world analysis of finerenone and steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease

Background Finerenone and steroidal mineralocorticoid receptor antagonists (sMRAs) reduce proteinuria in chronic kidney disease (CKD), but direct comparative data from routine clinical practice remain limited. The objective of this study was to compare the effectiveness, hemodynamic effects, kidney function trajectory, and safety of finerenone versus sMRAs in patients with proteinuric CKD in routine clinical practice. Methods This retrospective single-center cohort study included adults receiving finerenone or an sMRA between January 2021 and May 2025. Longitudinal analyses included 174 patients with at least one post-baseline assessment (finerenone, n = 96; sMRA, n = 78). Changes in proteinuria, estimated glomerular filtration rate (eGFR), blood pressure, potassium, and glycated hemoglobin were assessed using mixed-effects models. A 1:1 propensity score-matched sensitivity analysis was performed. Results Both treatments were associated with significant proteinuria reductions at 12 months, with percentage changes of −45.63% (95% confidence interval [CI], −59.42 to −27.15) with finerenone and −44.44% (95% CI, −60.08 to −22.66) with sMRAs, without a significant between-group difference (p = 0.927). Proteinuria reduction was already significant at 1 month with sMRAs, whereas it became significant from month 6 with finerenone. Both groups showed an early eGFR decline. At month 12, the decline remained significant in the sMRA group (−4.66 mL/min/1.73 m 2 ; 95% CI, −7.35 to −1.97) but not in the finerenone group; however, no significant between-group difference in eGFR trajectory was observed. sMRAs produced a greater reduction in systolic blood pressure at 12 months than finerenone, with a between-group difference of 7.24 mmHg (95% CI, 2.25–17.66). Serum potassium increased in both groups without a significant between-group difference. Treatment discontinuation was less frequent with finerenone than with sMRAs (13.8% vs. 28.7%; p = 0.021). Findings for proteinuria and eGFR were consistent in the matched sensitivity analysis. Conclusion In this real-world cohort, finerenone and sMRAs showed comparable antiproteinuric effectiveness. sMRAs were associated with a more pronounced blood pressure reduction, whereas finerenone showed more favorable renal profile, with lower treatment discontinuation and side effects.