Applying Recent Guidelines, 4-Pillared Approach to CKD Care

Management of chronic kidney disease among patients with type 2 diabetes has undergone significant change in the last decade. Once handcuffed by a lack of safe and efficacious options, changing standards of care coming as the result of pharmacotherapeutic advancement have ushered in a new era of management for this patient population.

This change has been spearheaded by 2 particular classes—a familiar face in the form of SGLT2 inhibitors and the novel nonsteroidal mineralocorticoid receptor antagonist (nsMRA) finerenone (Kerendia), which received approval in July 2021 for reducing the risk of sustained eGFR decline, kidney failure, cardiovascular death, non-fatal myocardial infarction, and hospitalization for heart failure in adult patients with chronic kidney disease associated with type 2 diabetes.

Finerenone first captivated the attention of nephrologists, endocrinologists, and other providers managing patients with type 2 diabetes with the release of data from the FIDELIO-DKD and FIGARO-DKD trials. The number of specialists captivated by the agent and its potential benefit grew with the release of data surrounding the cardiovascular benefits among patients with heart failure observed within the FINEARTS-HF trial at the European Society of Cardiology Congress 2024.

In this segment, which is part 4 of a 5-part series, discussants Edgar Lerma, MD, a nephrologist, and Anuradha Lala-Trindade, MD, a cardiologist, explore the substantial impact recent guideline updates have had on chronic kidney disease treatment strategies. Lerma details how clinicians increasingly employ an integrated approach, utilizing ACE inhibitors or ARBs, SGLT2 inhibitors, and finerenone as part of a multi-step, pillar-based strategy to slow chronic kidney disease progression. He notes that traditional protocols involve sequentially adding each treatment every 3 to 6 months, but recent discussions in publications, like one in Kidney360, propose accelerated options. These accelerated approaches may be more appropriate for high-risk patients, where clinicians can implement all therapies simultaneously to swiftly mitigate cardiovascular and renal complications.

Lerma also addresses the ongoing concern around hyperkalemia, especially when using mineralocorticoid receptor antagonists, which remains a potential side effect. He shares his anticipation for the FIND-CKD study, which may extend finerenone’s applications beyond diabetic chronic kidney disease, allowing more chronic kidney disease patients to benefit from its reno-protective effects.

Discussants Background:

Edgar Lerma, MD, a clinical professor of Medicine in the Section of Nephrology at the University of Illinois at Chicago and a nephrologist with Associates In Nephrology based in Chicago.

Anuradha Lala-Trindade, MD, the director of Heart Failure Research, program director of the Advanced Heart Failure and Transplant Fellowship, and associate professor of Medicine at The Mount Sinai Fuster Heart Hospital & Department of Population Health Science and Policy.

Relevant disclosures for Lerma include Akebia, Astra Zeneca, Bayer, Boehringer Ingelheim, Glaxo Smith Kline, Otsuka, Travere, Vifor, and Fresenius. Relevant disclosures for Lala-Trindade include Merck, AstraZeneca, Cytokinetics, and Novartis.

References:

1. Campbell P. Finerenone (Kerendia) approved for chronic kidney disease associated with type 2 diabetes. HCP Live. July 9, 2021. Accessed October 23, 2024. https://www.hcplive.com/view/finerenone-kerendia-approved-chronic-kidney-disease-associated-with-type-2-diabetes.
2. Campbell P. FDA updates Finerenone label to reflect Cardiovascular Outcomes Data. HCP Live. September 8, 2022. Accessed October 23, 2024. https://www.hcplive.com/view/fda-updates-finerenone-label-to-reflect-cardiovascular-outcomes-data.
3. Solomon SD, McMurray JJV, Vaduganathan M, et al. Finerenone in Heart Failure with Mildly Reduced or Preserved Ejection Fraction. N Engl J Med. Published online September 1, 2024. doi:10.1056/NEJMoa2407107