The organoprotective effects of finerenone in patients with cardiorenal metabolic syndrome

Type 2 diabetes mellitus (T2DM) is associated with hyperactivity of the renin-angiotensin-aldosterone system (RAAS), leading to increased aldosterone levels in the blood. This can result in the development and progression of chronic kidney disease (CKD) and congestive heart failure (CHF). High aldosterone levels, in turn, contribute to insulin resistance, microcirculatory disorders, mitochondrial dysfunction, oxidative stress, inflammation, dyslipidemia, and fibrosis. Additionally, in T2DM patients, persistent oxidative stress and hyperglycemia can trigger pathological activation of mineralocorticoid receptors, even in the absence of aldosterone or cortisol. This results in a vicious cycle of inflammation and fibrosis in the heart and kidneys. Therefore, targeting mineralocorticoid receptor (MCR) blockade is crucial for reducing fibrosis and other irreversible changes in CKD and CHF, as it can help break this cycle and reduce inflammation and fibrosis. However, spironolactone is not a highly selective MKR antagonist, which is one of the reasons for its many side effects. Eplerenone, with greater selectivity and lower affinity for the MKR, has a weaker cardioprotective effect due to its lower affinity. Finerenone, a first-in-class nonsteroidal mineralocorticoid receptor antagonist indicated for the treatment of CKD with albuminuria in adult patients with T2DM, provides the most significant anti-inflammatory and antifibrotic effects without the side effects associated with steroidal anti-inflammatory medications. The aim of this review is to evaluate the clinical trial results on the effects of finerenone on cardiovascular and renal outcomes in patients with T2DM. The review provides an up-to-date overview of the current literature on the impact of finerenone on these outcomes and systematically summarizes and describes additional positive cardioprotective benefits associated with its use.