Finerenone (Kerendia)
Finerenone is a nonsteroidal MRA that slows kidney disease progression and reduces cardiovascular events in adults with CKD and T2DM, based on the FIDELIO-DKD and FIGARO-DKD trials. The 2024 FINEARTS-HF trial expanded evidence into HFmrEF/HFpEF, with guideline incorporation progressing in 2026.
- Mechanism of action
- Selective nonsteroidal MR antagonist that blocks overactivation of mineralocorticoid signaling, reducing inflammatory and fibrotic drivers of kidney and cardiac disease.
- Administration route
- Oral, once daily
FDA-approved indications (2026)
CKD associated with T2DM
Reduction of risk of sustained eGFR decline, ESKD, CV death, non-fatal MI, and HF hospitalization.
Heart failure with mildly reduced or preserved EF (emerging)
FINEARTS-HF 2024 showed reduction in CV death and HF events; label expansion ongoing in 2026 (flagged: 2026-uncertain).
Dosing: adult, renal, and hepatic
| Population | Dose |
|---|---|
| eGFR ≥60 | Start 20 mg daily. |
| eGFR 25 to <60 | Start 10 mg daily; titrate to 20 mg after 4 weeks if K+ ≤4.8. |
| eGFR <25 | Do not initiate. |
| Serum potassium | Do not initiate if K+ >5.0. Hold if K+ >5.5; resume at lower dose when ≤5.0. Recheck K+ 4 wk after initiation and dose changes. |
| Hepatic impairment | Avoid in severe hepatic impairment (Child-Pugh C). Monitor closely in moderate impairment. |
Contraindications and boxed warnings
Contraindications
- Concomitant use of strong CYP3A4 inhibitors (e.g., itraconazole, clarithromycin).
- Adrenal insufficiency.
2026 guideline and pivotal trial position
KDIGO 2024 and ADA 2026 recommend finerenone for patients with CKD + T2DM who have albuminuria despite maximum tolerated RAS blockade, usually layered on an SGLT2 inhibitor. Emerging HFmrEF/HFpEF evidence from FINEARTS-HF is being integrated into 2026 ACC/AHA/HFSA focused updates.
FIDELIO-DKD
18% RRR in composite kidney outcome in CKD stage 3/4 with albuminuria + T2DM.
FIGARO-DKD
13% RRR in CV composite outcome, with HF hospitalization as the primary driver.
FIDELITY (pooled)
Consistent reduction in kidney and CV composite outcomes across CKD severity spectrum.
FINEARTS-HF (2024)
16% RRR in composite worsening HF or CV death in HFmrEF/HFpEF.
Cross-system reasoning
Finerenone sits at the nephrology-cardiology junction. In a patient with T2DM, eGFR 40, UACR 600 mg/g on maximum-tolerated ARB plus empagliflozin, finerenone adds incremental renal and CV protection with a more favorable hyperkalemia profile than steroidal MRAs. Careful potassium monitoring is essential when combined with ACE-I/ARB and especially when adrenal insufficiency or severe hepatic impairment is present. Avoid co-administration with strong CYP3A4 inhibitors.
Key references
- FDA Label — Kerendia (finerenone)
- Bakris GL, et al. FIDELIO-DKD (NEJM 2020)PMID: 33264825
- Pitt B, et al. FIGARO-DKD (NEJM 2021)PMID: 34449181
- Solomon SD, et al. FINEARTS-HF (NEJM 2024)PMID: 39225278
Related clinical reading
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This reference is for US-licensed physicians and is not a substitute for the full FDA prescribing information. Dosing in special populations, drug interactions, and emerging safety information should be verified against the current manufacturer label and society guidelines before prescribing.