Don't Jump to Kerendia for Diabetic Kidney Disease

Kerendia (finerenone) will be a new Rx for patients with chronic kidney disease (CKD) due to type 2 diabetes.

It's the first "nonsteroidal mineralocorticoid receptor antagonist"...and is approved to slow kidney disease progression and improve CV outcomes in these patients.

Kerendia is thought to limit fibrosis and inflammation in the kidneys and blocking effects of aldosterone.

Think of spironolactone or eplerenone as working similarly. But they're steroidal...and don't have evidence of improved CKD outcomes.

Adding once-daily Kerendia to max ACEI or ARB doses slows kidney disease progression in about 1 in 30 patients over 2.5 years...mostly due to less risk of significant eGFR decline, not kidney failure or death.

It also reduces risk of CV events in about 1 in 56 patients...likely due to reducing heart failure hospitalizations.

But think of Kerendia as a "niche" med...and weigh downsides.

It causes hyperkalemia in up to 1 in 11 not recommended in eGFR below 25 mL/min/1.73 m2...and costs about $570/month.

Instead, continue to first emphasize optimizing BP and glucose control...and maximizing ACEI or ARB doses.

If patients with CKD due to type 2 diabetes need a metformin add-on, consider an SGLT2 inhibitor (Jardiance, etc) or possibly a GLP-1 agonist (Victoza, etc)...especially for those at high CV risk.

Point out that these meds help protect the kidneys...improve CV outcomes...and lower glucose. Kerendia doesn't lower glucose.

Keep in mind, SGLT2 inhibitors have more evidence for CKD than GLP-1 agonists.

Save Kerendia as a last resort to slow progression of kidney disease in patients with type 2 diabetes...when an SGLT2 inhibitor or GLP-1 agonist isn't an option.

Don't recommend ADDING Kerendia to these meds for CKD...there's no evidence of additional benefit yet.

Advise monitoring potassium similar to an ACEI or baseline and within 4 weeks of starting Kerendia or adjusting the dose.

See our chart, Slowing Progression of Kidney Disease in Patients With Diabetes, for more on treatment and Kerendia's role.

Key References

  • N Engl J Med 2020;383(23):2219-29
  • N Engl J Med Published online Aug 28, 2021; doi:10.1056/NEJMoa2110956
  • Diabetes Care 2021;44(Suppl 1):S151-S167
  • Medication pricing by Elsevier, accessed Sep 2021
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