Pre-treatment estimated glomerular filtration rate trajectory modifies the renoprotective effect of finerenone in patients with chronic kidney disease associated with type 2 diabetes

In this study, we aimed to investigate whether pre-treatment estimated glomerular filtration rate (eGFR) trajectory modifies the effects of finerenone on kidney function and albuminuria in patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D) (CKD-T2D). This single-center retrospective study evaluated 60 patients with CKD-T2D treated with finerenone. The patients were categorized based on pre-treatment annual eGFR slope: Rising, Moderate-lowering, and Rapid-lowering. Linear mixed-effects models were used to assess longitudinal changes in eGFR and urinary albumin-to-creatinine ratio (UACR) over 12 months. A significant three-way interaction ( P = 0.0004) confirmed the heterogeneous responses. Finerenone significantly attenuated eGFR decline in patients with pre-treatment deterioration: Rapid-lowering group improved by 3.9 mL/min/1.73m 2 /year ( P = 0.005) and Moderate-lowering group by 2.3 mL/min/1.73m 2 /year ( P = 0.014). Conversely, the Rising group showed slope conversion from +1.99 to −1.30 mL/min/1.73m 2 /year ( P = 0.009). In the overall cohort, eGFR change was not significant ( P = 0.080). Notably, finerenone reduced UACR by approximately 32% overall cohort ( P < 0.0001), with consistent reductions of 24–45% across all subgroups. The renoprotective effect of finerenone was modified by pretreatment eGFR trajectory, with substantial attenuation of eGFR decline in the Rapid- and Moderate-lowering groups. Conversely, in patients with a rising pre-treatment eGFR trajectory, finerenone induced an initial negative shift in the eGFR slope; however, this was accompanied by a significant reduction in albuminuria, suggesting a hemodynamic stabilization of glomerular hyperfiltration. Classification based on pre-treatment trajectory might inform personalized therapy in patients with CKD-T2D. • Finerenone's renoprotective effect was modified by pretreatment eGFR trajectory. • Finerenone consistently reduced albuminuria in all the patient groups. • eGFR slope decline may not necessarily indicate future renal function decline. • To establish optimal treatment, considering pre-treatment eGFR trajectory is crucial.