Finerenone versus spironolactone in patients with chronic kidney disease and type 2 diabetes: a target trial emulation

Abstract

The comparative effectiveness of finerenone and spironolactone in chronic kidney disease (CKD) with type 2 diabetes (T2D) remains unclear. Here we show, using a target trial emulation on global real-world data from TriNetX, outcomes among 2268 propensity score–matched adults with CKD (eGFR 15–60 mL/min/1.73 m²) and T2D who initiated finerenone or spironolactone between July 2021 and September 2024. Over a median follow-up of 1.3 years, finerenone is associated with lower risks of major adverse cardiovascular events (adjust hazard ratio [aHR], 0.74; 95% CI, 0.58–0.94), major adverse kidney events (aHR, 0.47; 95% CI, 0.33–0.67), all-cause mortality (aHR, 0.31; 95% CI, 0.21–0.45), and hyperkalemia (17.2% vs. 26.4%; P < 0.001) compared with spironolactone. These findings suggest potential benefits of finerenone over spironolactone in reducing mortality and cardiorenal risk among patients with CKD and T2D.