Finerenone and cardiorenal outcomes in diabetic kidney disease: a systematic review and meta-analysis of randomized controlled trial evidence

Abstract

Among patients with type 2 diabetes (T2D), diabetic kidney disease (DKD) ranks among the foremost drivers of end-stage kidney disease and cardiovascular illness. Finerenone, a selective, nonsteroidal antagonist of the mineralocorticoid receptor, has been positioned as an agent that protects both heart and kidney. This systematic review and meta-analysis was conducted to estimate how finerenone affects albuminuria and composite kidney and cardiovascular endpoints in DKD. Four databases were searched from their earliest records through August 1, 2026, to locate studies testing finerenone in T2D patients with DKD. Using a random-effects, inverse-variance approach, the geometric mean ratio were pooled for change in urinary albumin-to-creatinine ratio (UACR) together with hazard ratios (HR) for the composite kidney and cardiovascular endpoints. Of 1,573 records identified, six articles satisfied the eligibility criteria. The UACR analysis drew on four trials (n ≤ 13,263), yielding a pooled ratio of 0.683 (95% CI 0.666-0.701; p < 0.0001), equivalent to a 32% placebo-corrected reduction, with essentially no between-study heterogeneity (I² ≤ 0%). For the two pivotal trials, FIDELIO-DKD and FIGARO-DKD (n ≤ 13,026), the pooled hazard ratios were 0.841 (95% CI 0.767-0.922) for the composite kidney endpoint and 0.865 (95% CI 0.788-0.950) for the composite cardiovascular endpoint. When layered onto optimized reninâ€"angiotensinâ€"aldosterone system blockade, finerenone meaningfully lowers albuminuria and cuts the risk of composite kidney and cardiovascular events in adults with T2D and DKD, a pattern that held consistently across the trials examined.