Finerenone outperforms spironolactone in real-world study of diabetic kidney disease

A major international analysis has found that finerenone offers better survival and stronger heart–kidney protection than spironolactone for people living with chronic kidney disease (CKD) and type 2 diabetes (T2D).

The research [1], led by National Taiwan University Hospital and published in Nature Communications (November 2025), drew on electronic health data from more than 2,200 patients across 21 countries. Using a sophisticated ‘target trial emulation’ approach, the team reconstructed the key features of a randomised clinical trial using real-world medical records — a method increasingly used to answer urgent clinical questions without waiting years for new trials.

The findings were striking. Compared with spironolactone, finerenone was associated with:

• A 69% reduction in all-cause mortality
• A 53% lower risk of major kidney deterioration or failure (MAKE)
• A 26% drop in major cardiovascular events (MACE)

Finerenone patients were also less likely to develop hyperkalaemia — a dangerous rise in blood potassium that often limits spironolactone use.

“Finerenone appears not only safer but also more effective in protecting both the heart and kidneys,” said Professor Vin-Cent Wu, nephrologist and senior author. “Our findings offer real-world confirmation that this drug may meaningfully change care for diabetic kidney disease.”

The team utilised the Global Health Network, covering 146 healthcare systems worldwide, and used advanced matching algorithms to balance demographic and clinical variables between treatment groups. This allowed the researchers to isolate drug effects more reliably than traditional observational studies.

Dr Chung-An Wang, first author, noted that this is the first real-world, head-to-head comparison of the two mineralocorticoid receptor antagonists. “Even over a median follow-up of just 1.3 years, the survival benefits of finerenone were clear,” he said.

Both medications work by blocking aldosterone, a hormone that drives inflammation and fibrosis in the kidneys and cardiovascular system. Finerenone’s more selective mechanism appears to maintain these protective effects while reducing risks linked to electrolyte imbalance.

Experts say the study’s insights could influence international guidelines and provide clinicians with more confidence when considering finerenone for patients at high cardiovascular or renal risk.

More information online

1. Chung-An Wang et al, Finerenone versus spironolactone in patients with chronic kidney disease and type 2 diabetes: a target trial emulation published in Nature Communications (2025). DOI: 10.1038/s41467-025-64640-3