eGFR- and Potassium-Guided Stewardship of SGLT2 Inhibitors and Finerenone in Albuminuric Chronic Kidney Disease Associated with Type 2 Diabetes
Abstract
Albuminuric chronic kidney disease (CKD) associated with type 2 diabetes remains a high-risk condition despite long-standing renin-angiotensin system (RAS) inhibition. Sodium-glucose cotransporter 2 (SGLT2) inhibitors and finerenone provide complementary kidney and cardiovascular protection through distinct hemodynamic, tubular, inflammatory, and fibrotic mechanisms. The Phase 2, randomized, double-blind Combination Effect of Finerenone and Empagliflozin in Participants with Chronic Kidney Disease and Type 2 Diabetes Using a Urinary Albumin-to-Creatinine Ratio Endpoint (CONFIDENCE) trial subsequently showed that simultaneous finerenone-empagliflozin initiation produced greater short-term albuminuria reduction than either monotherapy, but this biomarker benefit does not establish hard-outcome superiority or define the optimal sequencing strategy. This narrative review proposes a stewardship framework guided by estimated glomerular filtration rate (eGFR) and potassium for adults with albuminuric type 2 diabetes-associated CKD in whom SGLT2 inhibitors and finerenone are being implemented on a RAS-inhibition background. The review emphasizes that kidney protection depends not only on prescribing effective therapies, but also on maintaining exposure through initiation, monitoring, temporary interruption, de-escalation, and re-initiation. A modest early eGFR decline after SGLT2 inhibitor initiation usually reflects a functional hemodynamic response and should not be treated in…
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