Finerenone for the Treatment of Type 2 Diabetes-Related Kidney Disease: Efficacy Observation and Related Factor Analysis

This single-center prospective observational cohort study will recruit 425 eligible adult patients aged 18-75 years diagnosed with type 2 diabetes mellitus associated chronic kidney disease (T2DM-CKD) from the Chongqing Diabetes Registry, endocrine wards and outpatient clinics of the First Affiliated Hospital of Chongqing Medical University between February 2026 and January 2029. All enrolled subjects will receive guideline-directed finerenone oral therapy for a 4-month observation period, with dose adjusted based on baseline eGFR and serum potassium levels per drug instructions.

Serial blood and urine biospecimens will be collected at screening, baseline, month 1, month 2 and month 4 visits. Collected samples will be tested for routine biochemistry, electrolytes, renal function, HbA1c, plasma renin and aldosterone; captopril suppression test and multi-omics profiling will also be performed at designated time points.

According to the percentage reduction of urine albumin-to-creatinine ratio (UACR) at month 4, participants will be stratified into three subgroups: benefit group (UACR reduction ≥30%), partial benefit group (10% ≤ UACR reduction <30%), and non-benefit group (UACR reduction <10% or elevated UACR). Primary objective is to identify core biomarkers associated with finerenone therapeutic response. Secondary outcomes include serial changes in eGFR, UACR, serum potassium, aldosterone and renin across all follow-up time points.

Sample size calculation was performed using R pmsampsize package, accounting for a 10% anticipated loss to follow-up to reach the target sample of 425 subjects. All statistical analyses will be conducted via R and Python with machine learning algorithms to develop and validate a predictive model for finerenone efficacy.

Safety monitoring including serum potassium and renal function assessment will be conducted at every visit. Subjects with hyperkalemia or progressive renal impairment will suspend finerenone per predefined criteria. All study-related laboratory examinations are provided free of charge to participants, with priority medical consultation service available throughout follow-up. All personal clinical data and biological samples are anonymized and stored under encrypted management to protect participant privacy. Subjects may withdraw consent at any time without impact on routine clinical treatment. Study findings will be summarized and published in peer-reviewed journals after data collection is fully completed.

Inclusion criteria

• Aged 18-75 years, male or female, with full capacity for independent conduct.
• Confirmed type 2 diabetes-associated chronic kidney disease (CKD): Random urine albumin-to-creatinine ratio (UACR) of 100-5000 ug/mg Cr on two non-consecutive days; estimated glomerular filtration rate (eGFR) calculated by the CKD-EPI formula >25 mL/min/1.73m²; Finerenone treatment is indicated per clinical guidelines.
• All concomitant medications have remained stable for 3 months prior to screening, with no planned treatment adjustments throughout the trial. Stable medication is defined as dose adjustments not exceeding ±25% of the screening baseline dose.
• If the glycemic regimen includes sodium-glucose cotransporter 2 inhibitors (SGLT-2i): The daily SGLT-2i dose remains constant for 3 months before screening, and no daily dose changes are planned during the entire trial. If the glycemic regimen excludes SGLT-2i: No SGLT-2i exposure within 4 weeks prior to screening, and no SGLT-2i initiation is planned throughout the trial.
• If the glycemic regimen includes glucagon-like peptide-1 receptor agonists (GLP-1RA): The daily GLP-1RA dose remains constant for 3 months before screening, and no daily dose changes are planned during the entire trial. If the glycemic regimen excludes GLP-1RA: No GLP-1RA exposure within 4 weeks prior to screening, and no GLP-1RA initiation is planned throughout the trial.
• Fully understands the entire trial procedure, voluntarily participates in the study and signs the informed consent form.

Exclusion criteria

• Diagnosed or suspected type 1 diabetes, special type diabetes or secondary diabetes.
• Poor glycemic control with glycated hemoglobin (HbA1c) >9.0%.
• Average seated office blood pressure measured over 3 visits with systolic blood pressure >160 mmHg and/or diastolic blood pressure >100 mmHg.
• Serum potassium >5.0 mmol/L without potassium supplementation.
• Diagnosed or suspected chronic kidney disease unrelated to diabetic nephropathy.
• Complicated with liver cirrhosis or moderate-to-severe liver impairment.
• Patients with secondary aldosteronism and primary aldosteronism who have surgery plans within six months.
• Confirmed Addison's disease.
• Complicated with uncontrolled autoimmune diseases.
• Complicated with active malignant tumors.
• Presence or suspicion of depression, bipolar disorder, suicidal tendency, schizophrenia or other severe mental illnesses; or lack of mental capacity or language barrier, unable to fully understand the trial protocol or unwilling to cooperate with study site staff.
• Complicated with other uncontrolled chronic diseases.
• Use of serum potassium-elevating agents (e.g., amiloride, triamterene) or other mineralocorticoid receptor antagonists (MRAs, e.g., spironolactone, eplerenone) within 4 weeks prior to screening.
• Use of strong CYP3A4 inhibitors (itraconazole, ketoconazole, ritonavir, nelfinavir, cobicistat, clarithromycin, telithromycin, nefazodone) or CYP3A4 inducers (carbamazepine, phenytoin, erythromycin, fluvoxamine) within 2 weeks prior to screening.
• Pregnant or breastfeeding women.