A New Era in the Treatment of Chronic Kidney Disease in Type 2 Diabetes

 The information presented in the following questions and answers is entirely based on the scientific review “Clinical perspective—evolving evidence of mineralocorticoid receptor antagonists in patients with chronic kidney disease and type 2 diabetes”, published in 2022 in Kidney International Supplements (Volume 12, Pages 27–35).

The author of the publication is Professor Peter Rossing, an internationally recognized expert in diabetes and kidney disease. He is the Head of Complications Research at the Steno Diabetes Center Copenhagen (Denmark), and a professor at the Department of Clinical Medicine at the University of Copenhagen.

The article analyzes the latest and most reliable scientific information on the treatment of chronic kidney disease (CKD) in patients with type 2 diabetes, with a particular focus on the role of mineralocorticoid receptor antagonists—a class of medications that in recent years has transformed the approach to managing this serious and common complication.

“The new non-steroidal mineralocorticoid receptor antagonists, such as finerenone, offer effective protection for the kidneys and heart with minimal side effects—a true source of hope for people with diabetes and chronic kidney disease.”

Audio:

Expert Insights

Chronic kidney disease (CKD) in people with type 2 diabetes is one of the most pressing medical challenges in modern healthcare. It is associated with a high risk of kidney failure, cardiovascular disease, and significantly reduced life expectancy. Over the past decade, scientific advances have led to the development of new therapies aimed at slowing the progression of the disease and improving quality of life.

The following five expert perspectives and scientific insights feature quotes from leading researchers along with clear explanations to help patients and their families better understand current knowledge and make informed decisions about the best treatment options available.

1. How serious is the problem—and why are early diagnosis and monitoring so important?

“Diabetes is the leading cause of chronic kidney disease (CKD), which occurs in 30%–40% of people with diabetes. Globally, 537 million people—or 1 in 10—are living with diabetes, and this number is expected to reach 783 million by 2040. [...] It's important to note that most patients with CKD and diabetes die from cardiovascular disease, including atherosclerosis and heart failure.”

Explanation: This insight emphasizes not only the scale of the issue but also the importance of early detection and ongoing monitoring of kidney function in all individuals with diabetes. Regular screening for kidney disease and strict control of cardiovascular risk factors are strongly recommended.

2. Why isn’t standard therapy with renin-angiotensin system blockers enough?

“For years, the standard care for patients with CKD and diabetes has included therapy with angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs), along with blood sugar control. [...] The limited effect on kidney and cardiovascular outcomes is partly due to incomplete blockage of the renin-angiotensin system, as well as the so-called ‘aldosterone escape.’”

Explanation: This highlights why even the best standard therapies often fail to stop the progression of kidney disease and cardiovascular complications. Aldosterone may continue to play a harmful role despite RAS blockade, creating the need for new, complementary therapies.

3. What is the role of aldosterone and mineralocorticoid receptor antagonists?

“There is increasing focus on reducing aldosterone because of its harmful effects when it overactivates mineralocorticoid receptors (MR) in the kidneys and heart, leading to inflammation and fibrosis. In CKD, aldosterone is considered part of the disease process, and blocking it can be beneficial.”

Explanation: Overactivation of mineralocorticoid receptors promotes inflammatory and fibrotic processes in the kidneys and heart. Blocking MR is now seen as a key therapeutic strategy—not just for lowering blood pressure, but also for directly protecting organs.

4. What are the advantages and disadvantages of steroidal vs. non-steroidal antagonists?

“Traditional steroidal MR antagonists (such as spironolactone) reduce albuminuria, but long-term studies with hard endpoints like kidney function loss have not been conducted due to side effects, mainly hyperkalemia. New non-steroidal MR antagonists reduce proteinuria and markers of heart failure, with a lower risk of hyperkalemia.”

Explanation: Classical medications (like spironolactone) may be effective, but the risk of elevated potassium—which can be life-threatening—limits their use. New non-steroidal MR antagonists such as finerenone were designed to minimize these side effects while preserving the benefits.

5. What are the latest scientific findings and clinical recommendations?

“Recent clinical trials demonstrate the effectiveness of the new, selective, non-steroidal MR antagonist finerenone in slowing the progression of kidney and cardiovascular disease in patients with CKD and type 2 diabetes. [...] Finerenone has a favorable safety profile, with few patients discontinuing treatment due to hyperkalemia, even among those with low eGFR (>25 ml/min per 1.73 m²).”

Explanation: Finerenone, already approved by both the FDA and the European Medicines Agency, is now recommended as an add-on therapy for patients with CKD and type 2 diabetes. It reduces the risk of both kidney disease progression and cardiovascular complications, without major side effects. Combination with other new drugs, such as SGLT-2 inhibitors and GLP-1 receptor agonists, is also being explored.

Questions & Answers

1. Does it make sense to take two drugs to block the renin-angiotensin system if one isn’t enough? 

Answer: No. Dual therapy with both an ACE inhibitor and an ARB reduces proteinuria more than monotherapy, but it does not provide long-term benefits for kidney function in patients with CKD and type 2 diabetes. In fact, this approach carries a higher risk of serious side effects—particularly hyperkalemia (dangerously high blood potassium levels). For this reason, such studies were stopped early due to lack of benefit and increased risk.

2. Can a reduction in albuminuria (protein in the urine) be considered a sign that my treatment is working? 

Answer: Yes. Large meta-analyses show that a reduction in albuminuria following the start of antihypertensive therapy (e.g., with MR antagonists) is associated with slower progression of kidney disease and a lower risk of reaching end-stage kidney failure. For example, a 30% reduction in albuminuria compared to placebo correlates with an average 32% reduction in the risk of serious kidney outcomes (hazard ratio 0.68).

3. What were the inclusion and exclusion criteria for the recent finerenone trials? 

Answer: To be included in the FIGARO-DKD and FIDELIO-DKD trials, patients needed to have CKD and type 2 diabetes, an eGFR above 25 ml/min/1.73 m², and specific levels of albuminuria (UACR). They also needed to already be on optimized ACE inhibitor or ARB therapy and have blood potassium levels ≤4.8 mmol/L. Exclusion criteria included non-diabetic kidney disease, heart failure with reduced ejection fraction, uncontrolled diabetes (HbA1c >12%), or a recent serious cardiovascular event.

4. If I’m already taking an SGLT-2 inhibitor or a GLP-1 receptor agonist, should I still consider finerenone? 

Answer: Yes. According to the article, finerenone’s benefit in slowing kidney disease progression and reducing cardiovascular events is independent of whether a patient is already taking an SGLT-2 inhibitor or GLP-1RA. Moreover, combining it with an SGLT-2 inhibitor may reduce the risk of hyperkalemia (a known side effect of MR antagonists), as observed in trial data. This suggests that the two therapies can be combined for maximum kidney and heart protection, although more research is needed to determine the best combinations.

5. Are there any benefits of finerenone or other new therapies for complications beyond the kidneys—like diabetic retinopathy? 

Answer: There is scientific reason to believe that blocking mineralocorticoid receptors may also have a positive effect on other microvascular complications of diabetes, such as diabetic retinopathy (a leading cause of blindness in diabetes). Meta-analyses show that renin-angiotensin system inhibition reduces the risk of retinopathy progression, and there are preliminary data suggesting MR antagonists may help slow this complication. Dedicated sub-studies involving finerenone are underway, but definitive results and recommendations are not yet available.

Conclusion

This review of key questions and answers aims to help patients and their families better understand current options for diagnosing and treating chronic kidney disease in type 2 diabetes.

The analysis by Professor Rossing and his colleagues shows that with the advent of new medications like non-steroidal mineralocorticoid receptor antagonists (such as finerenone), patients can now access more effective and safer therapies that reduce the risk of both kidney disease progression and cardiovascular complications.

In conclusion, informed and personalized treatment based on the latest scientific evidence remains critical to improving quality of life and extending life expectancy in people with CKD and type 2 diabetes.

Source Rossing P. Clinical perspective—evolving evidence of mineralocorticoid receptor antagonists in patients with chronic kidney disease and type 2 diabetes. Kidney International Supplements (2022) 12, 27–35. https://doi.org/10.1016/j.kisu.2021.11.005