Recent trial data suggest finerenone could become one of the few drugs to address the long-standing treatment gap in kidney protection for type 1 diabetes, prompting cautious optimism among clinicians and a review of current guidelines.
Finerenone, a non-steroidal mineralocorticoid receptor antagonist, is beginning to look like one of the few drug classes with potential to close a long-standing treatment gap in type 1 diabetes and chronic kidney disease. In March, the FINE-ONE trial reported that adults with type 1 diabetes, CKD and albuminuria had a 25% greater reduction in urinary albumin-to-creatinine ratio after 6 months on finerenone than on placebo, on top of standard renin-angiotensin system treatment. That matters because albuminuria is widely used as a marker of kidney risk, even though the trial was not designed to prove hard outcomes such as kidney failure or death. (nejm.org)
The interest in the drug reflects a bigger problem: people with type 1 diabetes have had far fewer proven kidney-protective options than those with type 2 diabetes. Global estimates published this year suggest the burden of type 1 diabetes continues to rise, particularly in lower-income countries, while observational studies in Sweden, Norway and France have shown that cardiovascular and kidney disease are common in both major diabetes types, but chronic kidney disease is generally more frequent in type 2 diabetes. Those data underline why kidney-focused treatment advances matter so much for type 1 diabetes, where the therapeutic toolbox has remained thin. (nejm.org)
The latest guidance is cautiously receptive. The draft 2026 KDIGO diabetes-and-CKD update says finerenone can be considered for adults with type 1 diabetes, CKD, normal potassium and persistent albuminuria despite maximum tolerated ACE inhibitor or ARB therapy. It also acknowledges the limits of the evidence: FINE-ONE was short, relied on albuminuria as a bridging biomarker and did not establish long-term kidney or cardiovascular benefit in type 1 diabetes. Even so, KDIGO says the biological rationale is strong enough to support use while longer-term data are awaited. (kdigo.org)
That caution is echoed in commentary published in the New England Journal of Medicine, which said the lack of patients on SGLT2 inhibitors or GLP-1 receptor agonists in the finerenone trial leaves open the question of how much additional benefit it offers over newer cardio-kidney drugs. Still, the trial has sharpened the debate over a population that has long been under-served in nephrology research, and it has given clinicians the first substantial signal that finerenone may have a role in type 1 diabetic kidney disease. (nejm.org)
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