Recent findings from the FINEARTS-HF trial have sparked significant discussions regarding the renal protective effects of finerenone (Kerendia), particularly in patients with heart failure exhibiting mildly reduced or preserved ejection fraction. The secondary analysis suggests that finerenone may not yield the expected renal benefits in this demographic, despite being hailed as a promising treatment option for chronic kidney disease (CKD) linked to heart failure. This article delves into the implications of these findings and contextualizes them within the broader landscape of heart failure treatment.
The FINEARTS-HF trial’s data analysis revealed an unexpected trend: the composite outcome representing serious kidney deterioration—including a sustained decline of ≥50% in estimated glomerular filtration rate (eGFR) or the onset of kidney failure—occurred more frequently in the finerenone group compared to placebo (75 events vs. 55 events, hazard ratio [HR] 1.33). Furthermore, this scenario persisted with a more stringent definition of renal decline, underscoring a troubling reality for patients hoping to achieve renal improvement through this treatment. Remarkably, these results indicate a reversal of expectations surrounding finerenone, which was anticipated to provide renal protection in heart failure patients, particularly considering that CKD complicates the clinical course for nearly half of all heart failure patients.
Patient Population Characteristics
Finerenone’s underwhelming performance might, at least in part, be ascribed to the selected patient population. The participants in the FINEARTS-HF study generally presented low baseline risks for serious kidney events. With an average eGFR of 62 mL/min/1.73 m², it is clear that the cohort fell into a relatively stable group, diminishing the likelihood of large shifts in kidney function attributable to pharmacological intervention. Additionally, the historical presence of CKD among those with heart failure was noted, reiterating the connection between kidney dysfunction and adverse cardiovascular outcomes. This indicates that finerenone may not be the panacea researchers and healthcare providers had hoped, especially in lower-risk populations.
Despite lacking substantial improvements in eGFR metrics, finerenone demonstrated effectiveness in mitigating conditions such as microalbuminuria and macroalbuminuria. The anti-mineralocorticoid agent successfully reduced rates of new-onset microalbuminuria (HR 0.76) and macroalbuminuria (HR 0.62). It also notably lowered urine albumin-creatinine ratio (UACR) by 30% within the first six months. Although the implications of these findings warrant further investigation, the reduction in albuminuria could play a vital role in long-term cardiovascular protection by possibly staving off further renal deterioration over time.
Experts, including those not directly involved with the study like Dr. Ian de Boer, advocate for a cautious interpretation of these findings. Dr. de Boer highlights the long-term nature of CKD progression and indicates that while immediate renal benefits from finerenone might be lacking, the sustained reduction of albuminuria may eventually yield favorable eGFR outcomes. However, he notes that such a beneficial change is unlikely within the context of this lower-risk cohort, thus marking an essential distinction in treatment expectations.
Moreover, the dual challenge of managing heart failure and CKD compels physicians to rethink therapeutic strategies. As the average lifespan of CKD patients extends, integrated care pathways addressing both conditions become paramount. While finerenone’s approval was predicated on its effectiveness in other cardiac and renal risk metrics in patients with type 2 diabetes, results from FINEARTS-HF compel us to question its utility across varying heart failure and CKD severities.
The findings from the FINEARTS-HF trial introduce critical questions regarding the efficacy of finerenone in heart failure patients with mildly reduced or preserved ejection fraction. Although renally protective outcomes appeared limited, the drug did show promise in decreasing albuminuria, suggesting that it may still play a role in the multifaceted treatment approach to managing CKD and heart failure. As ongoing research continues to assess the long-term ramifications of treatment regimens, understanding the complex interplay of cardiovascular and renal health remains essential for optimizing patient outcomes in clinical practice.
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