A multidisciplinary expert consensus recommends finerenone for older adults with chronic kidney disease and albuminuria, meaning albumin in the urine, when their estimated glomerular filtration rate, or eGFR, is at least 25 mL/min/1.73 m2. It favors use in people at high kidney or cardiovascular risk and says finerenone may be combined with a renin-angiotensin system inhibitor or an SGLT2 inhibitor when appropriate. The recommendation applies to people with or without diabetes.
That recommendation comes from a literature-based consensus, not a new treatment trial. The article enrolled no participants and contains no original research dataset. Its working group brought together geriatrics, cardiovascular medicine, endocrinology, nephrology and epidemiology. The group searched PubMed, Embase, CNKI and Wanfang Data through August 26, 2025, registered the consensus as PREPART-2025CN954 and held three workshop rounds between September 2024 and September 2025.
The kidney case rests on broader adult trials
The kidney evidence highlighted by the consensus includes FIDELIO-DKD and FIGARO-DKD, placebo comparisons in adults with type 2 diabetes and chronic kidney disease. FIDELIO-DKD included 5,734 adults and reported 18% lower risk for a renal composite outcome and 14% lower risk for a cardiovascular composite outcome with finerenone than placebo. FIGARO-DKD included 7,437 adults and reported 13% and 23% lower risks for its cardiovascular and renal composite outcomes. The review also reported 31% and 32% reductions in albuminuria, or albumin in the urine, after four months in the two trials, respectively.
The recommendation is broader than the main randomized evidence: the cited trials mainly concern adults with type 2 diabetes and chronic kidney disease, not populations made up exclusively of older people. The review reports relative percentages but no absolute event rates or statistical ranges around those estimates, known as confidence intervals. That leaves the size of the difference in everyday risk unclear from the document alone.
In a Chinese FIDELITY subgroup of 697 patients, the review reports 43% lower renal composite risk with finerenone. Among patients with a history of atherosclerotic cardiovascular disease, it reports 17% lower cardiovascular composite risk, 18% lower risk of cardiovascular death or heart-failure hospitalization and 15% lower all-cause mortality. Among those without that history, the reported cardiovascular composite reduction was 9%. The consensus identifies these as subgroup findings and gives no confidence intervals or absolute event rates for them.
Heart-failure evidence has a clear boundary
The heart-failure evidence comes from FINEARTS-HF, which enrolled 6,001 symptomatic patients from 37 countries or regions. Participants had a left ventricular ejection fraction of at least 40%, a heart-pumping measure used in the study. Over a median follow-up of 32 months, the trial reported 16% lower risk for its primary endpoint and 18% lower risk for overall heart-failure events with finerenone than placebo. It also reported a 38% reduction in cardiovascular death and overall heart-failure events by day 28, plus greater improvement in a heart-failure symptom score.
Safety results were more mixed. Serious adverse events were reported at similar rates, 38.7% with finerenone and 40.5% with placebo. Hyperkalemia, meaning high blood potassium, was reported in 9.7% of patients taking finerenone and 4.2% taking placebo. Hypokalemia, meaning low blood potassium, occurred in 4.4% and 9.7%, respectively. The review describes hospitalization and treatment discontinuation because of hyperkalemia as low, but does not supply event rates for those outcomes.
The document says finerenone may be considered for older patients with heart failure with reduced ejection fraction, or HFrEF, when chronic kidney disease is also present or when steroidal mineralocorticoid receptor antagonists are not tolerated. But it explicitly notes that finerenone has no approved indication for HFrEF treatment. That makes this a consensus suggestion for selected cases, not a regulatory approval.
For older patients, monitoring is central
Older age alone does not trigger a different finerenone dose under the consensus. Instead, it calls for individualized assessment and close monitoring of blood pressure, serum potassium, renal function, drug interactions, nutrition, frailty and cognition. The document acknowledges that evidence is limited in the very elderly, frail and severely malnourished.
Hypertension alone is a different story. The consensus says evidence for primary hypertension alone is lacking. It cites a 3.7 mmHg systolic blood-pressure reduction versus placebo in FIDELITY, while ambulatory blood-pressure monitoring reported reductions of 8.3, 11.2 and 9.9 mmHg with finerenone doses of 10, 15 and 20 mg/day. The review notes that these findings come from pooled, post hoc and subgroup analyses.
Cognition is also an open question. The consensus reports no identified clinical-trial signal of finerenone-related cognitive impairment, but says direct cognitive effects have not been reported and any possible neuroprotective effect remains theoretical. That is why cognition appears among the factors clinicians are urged to consider alongside potassium, kidney function, nutrition, frailty and drug interactions.
Several important questions remain
The consensus identifies ongoing studies in broader heart-failure populations, non-diabetic chronic kidney disease, type 1 diabetes with chronic kidney disease and routine clinical practice. It also leaves open how finerenone should be dosed and monitored in the oldest-old, frail and severely malnourished, and whether it directly affects cognitive outcomes. Until those questions are answered, the guidance emphasizes individualized assessment and close monitoring.
The consensus was funded by the Key Research and Development Program of Shaanxi Province under grant 2024SF-ZDCYL-01-12. The authors declare no conflicts of interest.
Paper data and sources
Original title: Chinese Expert Consensus on the Clinical Application of Finerenone in Geriatric Comorbidities: Geriatrics Branch of Chinese Medical Association, Cardiovascular Group of Geriatrics Branch of Chinese Medical Association.
Authors: Xiaoming Wang, Cuntai Zhang
Journal/Repository: Aging medicine (Milton (N.S.W))
Status: Peer-reviewed
First online: 2026-08-20
DOI: 10.1002/agm2.70103
Original paper