Effects of Contemporary Therapies on Cardiovascular and Renal Outcomes in Diabetic Kidney Disease: A Systematic Review of Randomized Controlled Trials (RCTs)

This systematic review evaluated the impact of contemporary therapies on cardiovascular (CV) and renal outcomes in patients with diabetic kidney disease (DKD), with a particular focus on finerenone as a novel nonsteroidal mineralocorticoid receptor antagonist. Across eight eligible studies involving more than 13,000 participants with type 2 diabetes and chronic kidney disease (CKD), finerenone consistently reduced the risk of composite CV events, including CV death, myocardial infarction, stroke, and hospitalization for heart failure, as well as composite renal outcomes such as kidney failure, sustained estimated glomerular filtration rate decline, or renal death. Subgroup analyses demonstrated that these benefits extended across diverse populations, including patients with stage 4 CKD, those stratified by age and sex, and individuals receiving diuretics, GLP-1 receptor agonists, or with baseline left ventricular hypertrophy. Importantly, the renal protective effects appeared dose-dependent up to 20 mg daily, with safety concerns primarily limited to an increased incidence of hyperkalemia, though discontinuation rates remained low. An earlier comparative trial of renin-angiotensin system inhibitors showed no significant differences between agents but highlighted tolerability advantages with angiotensin receptor blockers. Collectively, these findings reinforce the role of finerenone as an effective therapy for cardiorenal risk reduction in DKD, while also identifying areas for further research including advanced kidney disease, long-term renal preservation, and combination therapy strategies.