A 55-year-old man with type 2 diabetes, proteinuria (urine albumin-creatinine ratio 850 mg/g), and eGFR 42 mL/min/1.73m² is on maximum-dose ACE inhibitor and SGLT-2 inhibitor. Which additional therapy has been shown in the FIDELIO-DKD and FIGARO-DKD trials to reduce CKD progression and cardiovascular events in diabetic kidney disease?
- A Finerenone (selective non-steroidal mineralocorticoid receptor antagonist) ✓
- B Spironolactone (steroidal MRA) added to ACE inhibitor
- C Atrasentan (endothelin receptor antagonist)
- D Bardoxolone methyl (Nrf2 activator)
Explanation
Finerenone is a selective, non-steroidal mineralocorticoid receptor antagonist (MRA) that has demonstrated reduction in CKD progression (composite of kidney failure, sustained ≥ 40% eGFR decline, or renal death) by 18% and cardiovascular events by 13% in the FIDELIO-DKD trial. The FIGARO-DKD trial confirmed cardiovascular benefit. Combined analysis (FIDELITY) showed reduction in both endpoints. Unlike spironolactone, finerenone has lower selectivity-related side effects (less gynaecomastia) and does not cause the same degree of hyperkalaemia, though K+ monitoring remains important. It is now recommended by KDIGO 2022 as part of the 'four pillars' of DKD treatment (ACEi/ARB + SGLT-2 inhibitor + GLP-1 RA/finerenone). Bardoxolone was withdrawn due to safety concerns.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.