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

Chung-An Wang; Hsuan-Wen Lai; Jui-Yi Chen; Wei-Jie Wang; Li-Chun Lin; Yen-Ling Chiu; Chung-Yi Cheng; Vin-Cent Wu

doi:10.1038/s41467-025-64640-3

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

Nat Commun. 2025 Oct 31;16(1):9641. doi: 10.1038/s41467-025-64640-3.

Authors

Chung-An Wang^{1

2}, Hsuan-Wen Lai^{2

3}, Jui-Yi Chen^{4

5}, Wei-Jie Wang^{6

7}, Li-Chun Lin^{8

9}, Yen-Ling Chiu^{10

11}, Chung-Yi Cheng^{12

13

14}, Vin-Cent Wu^{15

16

17}

Affiliations

¹ Far Eastern Memorial Hospital, New Taipei City, Taiwan, ROC.
² Taipei Medical University, Taipei, Taiwan, ROC.
³ Cathay General Hospital, Taipei, Taiwan, ROC.
⁴ Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan, ROC.
⁵ Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan, ROC.
⁶ Division of Nephrology, Department of Internal Medicine, Lo-Sheng Sanatorium and Hospital, Ministry of Health and Welfare, New Taipei, Taiwan, ROC.
⁷ Department of Biomedical Engineering, Chung Yuan Christian University, Chungli, Taiwan, ROC.
⁸ Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC.
⁹ Primary aldosteronism center of (PAC) Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC.
¹⁰ Program of Biomedical Informatics, Yuan Ze University, Zhongli District, Taoyuan City, Taiwan, ROC.
¹¹ Department of Medical Research, Far Eastern Memorial Hospital, New Taipei, Taiwan, ROC.
¹² Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC.
¹³ Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC.
¹⁴ Taipei Medical University-Research Center of Urology and Kidney (RCUK), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC.
¹⁵ Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC. q91421028@ntu.edu.tw.
¹⁶ Primary aldosteronism center of (PAC) Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC. q91421028@ntu.edu.tw.
¹⁷ National Taiwan University Hospital Study Group of Acute Renal Failure (NSARF) and Taiwan Consortium for Acute Kidney Injury and Renal Diseases, Taipei, Taiwan, ROC. q91421028@ntu.edu.tw.

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.

Publication types

Comparative Study

MeSH terms

Aged
Cardiovascular Diseases
Diabetes Mellitus, Type 2* / complications
Diabetes Mellitus, Type 2* / drug therapy
Diabetes Mellitus, Type 2* / mortality
Female
Glomerular Filtration Rate / drug effects
Humans
Hyperkalemia
Male
Middle Aged
Mineralocorticoid Receptor Antagonists / therapeutic use
Naphthyridines* / adverse effects
Naphthyridines* / therapeutic use
Propensity Score
Renal Insufficiency, Chronic* / complications
Renal Insufficiency, Chronic* / drug therapy
Renal Insufficiency, Chronic* / mortality
Spironolactone* / adverse effects
Spironolactone* / therapeutic use
Treatment Outcome

Substances

Spironolactone
finerenone
Naphthyridines
Mineralocorticoid Receptor Antagonists