Finerenone Associated with Lowered BP in T2D and DKD

Key Takeaways

• Finerenone initiation was associated with a generally lower systolic and diastolic blood pressure pattern over the first week in hypertensive patients with type 2 diabetes and diabetic kidney disease.
• The blood pressure decline often appeared within 24 to 48 hours after finerenone started, with the most pronounced overall shifts by 48 to 72 hours.
• Heart rate remained stable and trended downward in cohort-level analyses rather than showing reflex tachycardia.

Investigators at Shanghai Pudong Hospital, Fudan University studied finerenone's impact on hemodynamics in a retrospective single-center observational review of electronic medical records from March to November 2024, published inFrontiers in Endocrinology. The analysis included 462 hospitalized patients with confirmed type 2 diabetes mellitus and diabetic kidney disease who began finerenone (10 mg or 20 mg once daily) during admission. Patients were grouped as Fine 1 through Fine 5 according to treatment start day. Systolic blood pressure, diastolic blood pressure, and heart rate were measured morning and afternoon for 7 days after at least 10 minutes of supine rest with standardized automated oscillometric monitors. A non-finerenone hypertensive comparison group was included for context because those patients had lower albuminuria and did not meet local insurance criteria for finerenone.

Age, serum potassium, estimated glomerular filtration rate (eGFR), aldosterone, plasma renin concentration (PDC), and aldosterone-to-renin ratio (ARR) did not differ significantly at baseline. Against that background, systolic and diastolic blood pressure declined after finerenone initiation. The largest blood pressure reductions were often seen within 24 to 48 hours after initiation, and statistical analyses indicated the most pronounced systolic and diastolic changes overall occurred within 48 to 72 hours. The hypertensive response was more pronounced in patients with elevated baseline ARR, suggesting ARR's potential as a biomarker. Heart rate remained generally stable, with detailed cohort analyses showing a downward trend and no reported pattern of reflex tachycardia. Baseline angiotensin receptor blocker (ARB), calcium channel blocker (CCB), and sodium-glucose cotransporter-2 inhibitor use was 90.6%, 84.6%, and 91.4%, and core antihypertensive regimens remained largely unchanged through Days 1 to 3, with only slight later calcium channel blocker variation.

Because this was a retrospective observational analysis from a single Shanghai inpatient center, the findings describe associations rather than causation. Timing of finerenone initiation may have reflected clinical selection, and the 7-day window captures only the earliest in-hospital response. The findings do not establish outpatient effectiveness, long-term safety, or effects on end-stage renal disease or major adverse cardiovascular events. The authors argued that largely stable background regimens support finerenone as the main driver of the early blood pressure change, but that interpretation remains within an observational design.

Clinician Questions

Could changes in background antihypertensive therapy explain the early blood pressure reductions?

Core antihypertensive therapy remained largely stable during the first 3 days after finerenone initiation. This reduced—but, given the observational design, did not eliminate—the possibility that treatment changes other than finerenone contributed to the early blood pressure reductions.

Was baseline ARR linked to finerenone’s early blood pressure response in diabetic kidney disease?

The authors described a more pronounced rapid antihypertensive response among patients with an elevated baseline aldosterone-to-renin ratio and suggested that ARR could potentially serve as a predictive biomarker.

What does this first-week finerenone study leave unanswered about longer-term diabetic kidney disease outcomes?

The 7-day inpatient observation window cannot determine whether finerenone initiation affects end-stage renal disease, major adverse cardiovascular events, outpatient effectiveness, or long-term safety, and the authors called for prospective studies to test whether the acute hemodynamic response predicts later renal or cardiovascular outcomes.