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Efficacy of finerenone in reducing proteinuria in diabetic kidney disease with maximum tolerable doses of dapagliflozin and telmisartan
Amit S Pasari, Sushrut Gupta, Prasad Gurjar, Vishal Ramteke, Sunny Malde, Twinkle Pawar, Vijay Jeyachandran, Pranjal Kashiv, Shubham Dubey, Mohit Kurundwadkar, Kapil Sejpal, Charulata Bawankule, Nishant Deshpande, Manish Ramesh Balwani
Amit S Pasari, Sushrut Gupta, Prasad Gurjar, Sunny Malde, Twinkle Pawar, Vijay Jeyachandran, Shubham Dubey, Mohit Kurundwadkar, Kapil Sejpal, Charulata Bawankule, Manish Ramesh Balwani, Department of Nephrology, Jawaharlal Nehru Medical College, Wardha 442001, Mahārāshtra, India
Amit S Pasari, Charulata Bawankule, Manish Ramesh Balwani, Department of Nephrology, Saraswati Kidney Care Centre, Nagpur 440015, Mahārāshtra, India
Vishal Ramteke, Nishant Deshpande, Department of Nephrology, Max Super Speciality Hospital, Nagpur 440030, Mahārāshtra, India
Pranjal Kashiv, Department of Nephrology, All India Institute of Medical Sciences, Nagpur, Nagpur 441108, Mahārāshtra, India
Co-first authors: Amit S Pasari and Sushrut Gupta.
Author contributions: Gupta S contributed to conceptualization, methodology, supervision; Kashiv P, Gurjar P, Malde S, Pawar T, and Jeyachandran V contributed to data collection, investigation, writing, original draft; Balwani MR, Ramteke V, Dubey S, Kurundwadkar M, Sejpal K, Bawankule C, Deshpande N, contributed to formal analysis, validation, writing, review and editing; Pasari AS contributed to resources, project administration, final approval; Pasari AS and Gupta S have made crucial and indispensable contributions towards the completion of the project and thus qualified as the co-first authors of the paper; all authors read and approved the final manuscript.
Institutional review board statement: The study adhered to the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the institutional ethics committee before the commencement of the study. Name of Approval committee SKCC Institutional Ethics Committee (SS Multispecialty Hospital) (No. SKCC/IEC/2025/02/PN04). No identifiable personal information was accessed or utilized in the analysis. All data handling and analysis were carried out in strict adherence to ethical standards for the use of retrospective, anonymized data, ensuring participant confidentiality and privacy.
Informed consent statement: This retrospective study used anonymized data collected from medical records, and no identifiable personal information was included. According to the institutional ethics committee guidelines, individual consent for publication was not required.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No new data were generated or analyzed in this study. Data sharing is not applicable to this article.
Corresponding author: Vishal Ramteke, MD, Department of Nephrology, Max Super Speciality Hospital, Mankapur Square, Koradi Road, Nagpur 440030, Mahārāshtra, India.
vvramteke@gmail.com
Received: December 1, 2025
Revised: January 2, 2026
Accepted: January 26, 2026
Published online: March 25, 2026
Processing time: 104 Days and 0.8 Hours
BACKGROUND
Diabetic kidney disease (DKD) remains a leading cause of end-stage renal disease (ESRD), with persistent proteinuria contributing to renal and cardiovascular complications. Despite dual therapy with renin-angiotensin-aldosterone system (RAAS) blockers and sodium-glucose co-transporter-2 inhibitors (SGLT2is), residual proteinuria persists in a substantial subset of patients. Finerenone, a novel nonsteroidal mineralocorticoid receptor antagonist, has shown promise in reducing albuminuria and slowing chronic kidney disease progression. This study evaluated the additive effect of finerenone exclusively in patients receiving maximum tolerable doses of both dapagliflozin and telmisartan unlike previously available studies evaluating its effect on patients with maximum tolerated dose of angiotensin receptor blocker alone.
AIM
To evaluate the efficacy and safety of finerenone in reducing proteinuria in patients with DKD who were receiving maximally tolerated doses of dapagliflozin and telmisartan.
METHODS
A retrospective, single-center observational study evaluated 33 patients with DKD and residual proteinuria. All patients received finerenone 10 mg daily for 24 weeks. Key parameters assessed at baseline and follow-up included urinary albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate, and serum potassium. Responders were defined as patients who exhibited a reduction in UACR at follow-up.
RESULTS
The mean reduction in UACR was 9.5% (P = 0.256). Twenty-two patients (66.7%) responded to treatment with a reduction in UACR, while 11 patients (33.3%) showed no reduction. When stratified by baseline albuminuria, responders with initial UACR < 1000 mg/g, 1000-3000 mg/g, and > 3000 mg/g showed average reductions of -47.9%, -39.0%, and -32.8%, respectively, suggesting a gradient treatment effect. Finerenone was well tolerated with mild hyperkalemia (serum potassium > 5.0 mmol/L) noted in 15.2% of patients with mean increase in serum potassium by 6.4% (P = 0.016). No cases required treatment discontinuation due to hyperkalemia. Renal function remained stable during the study.
CONCLUSION
Finerenone was associated with an overall reduction in albuminuria, with the magnitude of response varying according to baseline UACR. Greater proportional reductions were observed in patients with lower baseline albuminuria, while patients with moderate to severe albuminuria demonstrated a more heterogeneous response, including both responders and non-responders. Despite this variability, finerenone was generally safe and well tolerated. These findings support the use of finerenone as part of a multimodal strategy for proteinuria management in DKD, particularly as add-on therapy in patients receiving optimized RAAS blockade and SGLT2 inhibition, with the greatest benefit seen when introduced earlier in the course of albuminuric disease.
Core Tip: Diabetic nephropathy is the leading cause of end-stage renal disease worldwide and proteinuria reduction is the cornerstone in the management. In some patients even with dual therapy with renin-angiotensin-aldosterone system blockers and sodium-glucose co-transporter-2 inhibitors, residual proteinuria persists. Finerenone, a novel nonsteroidal mineralocorticoid receptor antagonist has shown results reducing albuminuria and slowing chronic kidney disease progression. This study evaluated the additive effect of finerenone exclusively in patients receiving maximum tolerable doses of both dapagliflozin and telmisartan unlike previously available studies evaluating its effect on patients with maximum tolerated dose of angiotensin receptor blocker alone.
