Finerenone versus Steroidal MRAs in Type 2 Diabetes and Chronic Kidney Disease without Prior Heart Failure

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.