The efficacy of finerenone, a selective non-steroidal mineralocorticoid receptor antagonist, has been put to the test in patients suffering from heart failure with mildly reduced or preserved ejection fractions. A recent analysis of the FINEARTS-HF trial provides meaningful insights into its renal benefits, particularly in relation to kidney function stability. This review critically examines the findings of this trial while considering the broader implications of renal outcomes for heart failure patients.
According to the secondary analysis presented by Finnian R. McCausland from Brigham and Women’s Hospital, finerenone conferred minimal renal benefits to its recipients when assessed against a composite kidney outcome. Notably, the trial found a greater incidence of significant kidney outcomes among those treated with finerenone compared to placebo (75 vs. 55 events), suggesting a hazard ratio (HR) of 1.33 (95% confidence interval [CI] 0.94-1.89). This underscores a disconcerting trend where the administration of finerenone does not yield the anticipated protection against renal deterioration. Furthermore, even when a more severe definition of kidney impairment was employed (≥57% eGFR decline or kidney failure with 41 vs. 31 events), the HR remained high at 1.28 (95% CI 0.80-2.05), further potentially questioning the drug’s utility in this specific demographic of patients.
The study population—which primarily comprised older adults with an average estimated glomerular filtration rate (eGFR) of 62 mL/min/1.73 m² and a demographic heavily skewed toward Caucasians—could be perceived as already possessing a relatively low risk of adverse renal events. These patients, who typically exhibit coexisting chronic kidney disease (CKD), which affects nearly half of individuals with heart failure, face increased morbidity and mortality rates compared to their non-CKD counterparts. This context is vital as it complicates the interpretation of finerenone’s impact on renal outcomes.
CKD poses a significant challenge within the heart failure population, manifesting as a compounding risk factor that can exacerbate cardiovascular morbidity. McCausland highlights the potent predictor role of albuminuria in determining cardiovascular and kidney outcomes. While the analysis indicated a lack of significant renal benefits, it did reveal that finerenone was effective in lowering the incidence of new-onset microalbuminuria (HR 0.76, 95% CI 0.68-0.83) and macroalbuminuria (HR 0.62, 95% CI 0.53-0.73). A decrease in urine albumin-creatinine ratio (UACR) by an impressive 30% was also recorded over six months.
These ancillary findings may suggest a potential avenue for long-term benefits in kidney function, despite the immediate shortcomings evidenced in eGFR stabilization. As commented by Ian de Boer, MD, this population’s relatively brief follow-up duration may preclude any observed significant long-term outcomes, highlighting an essential gap in our understanding of how treatments for CKD evolve over extended periods.
The emerging data from the FINEARTS-HF trial calls for a critical reassessment of the expected benefits of finerenone in heart failure patients with co-existing renal issues. The initial approval of finerenone in 2021 was based on its capability to mitigate the risk of sustained eGFR decline among patients with CKD associated with type 2 diabetes, paving the way for its anticipated renal benefits in other populations. However, the limitations highlighted by the FINEARTS-HF trial demand cautious application of this therapeutic agent for individuals suffering from heart failure with mildly reduced or preserved ejection fraction.
Clinicians must now navigate the complex landscape of treating heart failure in synergy with renal impairment. Given that serious adverse events were noted at a comparable frequency across both treatment arms, practitioners ought to weigh the benefits of finerenone’s reduction in albuminuria against the higher risk observed for significant eGFR decline—essentially a balances act of risk versus reward.
While finerenone demonstrates some efficacy in the management of microalbuminuria and macroalbuminuria, its role in protecting renal function remains tenuous in the context of heart failure patients with mildly reduced or preserved ejection fractions. The findings from the FINEARTS-HF trial illuminate the challenges faced in treating this particular patient demographic and stress the importance of ongoing research to clarify the drug’s long-term implications on renal health. As the medical community garners greater insights from such studies, refining treatment modalities for heart failure with concurrent CKD ultimately empowers better patient outcomes.
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