Modifiability of Composite Cardiovascular Risk Associated With Chronic Kidney Disease in Type 2 Diabetes With Finerenone

Abstract

Importance: It is currently unclear whether chronic kidney disease (CKD)-associated cardiovascular risk in type 2 diabetes (T2D) is modifiable.

Objective: To examine whether cardiovascular risk can be modified with finerenone in patients with T2D and CKD.

Design, setting, and participants: Incidence rates from Finerenone in Chronic Kidney Disease and Type 2 Diabetes: Combined FIDELIO-DKD and FIGARO-DKD Trial Programme Analysis (FIDELITY), a pooled analysis of 2 phase 3 trials (including patients with CKD and T2D randomly assigned to receive finerenone or placebo) were combined with National Health and Nutrition Examination Survey data to simulate the number of composite cardiovascular events that may be prevented per year with finerenone at a population level. Data were analyzed over 4 years of consecutive National Health and Nutrition Examination Survey data cycles (2015-2016 and 2017-2018).

Main outcomes and measures: Incidence rates of cardiovascular events (composite of cardiovascular death, nonfatal stroke, nonfatal myocardial infarction, or hospitalization for heart failure) were estimated over a median of 3.0 years by estimated glomerular filtration rate (eGFR) and albuminuria categories. The outcome was analyzed using Cox proportional hazards models stratified by study, region, eGFR and albuminuria categories at screening, and cardiovascular disease history.

Results: This subanalysis included a total of 13 026 participants (mean [SD] age, 64.8 [9.5] years; 9088 male [69.8%]). Lower eGFR and higher albuminuria were associated with higher incidences of cardiovascular events. For recipients in the placebo group with an eGFR of 90 or greater, incidence rates per 100 patient-years were 2.38 (95% CI, 1.03-4.29) in those with a urine albumin to creatinine ratio (UACR) less than 300 mg/g and 3.78 (95% CI, 2.91-4.75) in those with UACR of 300 mg/g or greater. In those with eGFR less than 30, incidence rates increased to 6.54 (95% CI, 4.19-9.40) vs 8.74 (95% CI, 6.78-10.93), respectively. In both continuous and categorical models, finerenone was associated with a reduction in composite cardiovascular risk (hazard ratio, 0.86; 95% CI, 0.78-0.95; P = .002) irrespective of eGFR and UACR (P value for interaction = .66). In 6.4 million treatment-eligible individuals (95% CI, 5.4-7.4 million), 1 year of finerenone treatment was simulated to prevent 38 359 cardiovascular events (95% CI, 31 741-44 852), including approximately 14 000 hospitalizations for heart failure, with 66% (25 357 of 38 360) prevented in patients with eGFR of 60 or greater.

Conclusions and relevance: Results of this subanalysis of the FIDELITY analysis suggest that CKD-associated composite cardiovascular risk may be modifiable with finerenone treatment in patients with T2D, those with eGFR of 25 or higher, and those with UACR of 30 mg/g or greater. UACR screening to identify patients with T2D and albuminuria with eGFR of 60 or greater may provide significant opportunities for population benefits.

Figure 1.. Predicted Probability of a Composite Cardiovascular (CV) Event at 4 Years by Continuous Urine Albumin to Creatinine Ratio (UACR) and Estimated Glomerular Filtration Rate (eGFR)

Patients with eGFR less than 60 (A) or greater than or equal to 60 (B). Patients with UACR less than 300 mg/g (C) or greater than or equal to 300 mg/g (D). The Cox proportional hazards model was fitted with the covariates treatment, study, CV disease history, region, sex, and race, and the continuous covariates age, hemoglobin A_1c, systolic blood pressure, baseline UACR (log transformed), and eGFR at baseline. Cubic B-splines were used for log-transformed UACR (A and B) and eGFR (C and D). Vertical lines highlight predicted probability of composite CV events at key UACR and eGFR thresholds.

Figure 2.. Composite Cardiovascular (CV) Risk Reduction by Finerenone Across Estimated Glomerular Filtration Rate (eGFR) and Albuminuria Categories: Finerenone in Chronic Kidney Disease and Type 2 Diabetes: Combined FIDELIO-DKD and FIGARO-DKD Trial Programme Analysis (FIDELITY) Incidences and Population-Level Estimates

Error bars represent 95% CIs. Colors represent KDIGO risk categories. A, National Health and Nutrition Examination Survey (NHANES)–estimated prevalence of individuals eligible for finerenone with chronic kidney disease (CKD) and type 2 diabetes (T2D) in the US by Kidney Disease: Improving Global Outcomes (KDIGO), eGFR, and albuminuria categories. B, Excess number of patients with CV event per 10 000 person-years (PY) in FIDELITY with finerenone vs placebo across KDIGO, eGFR, and albuminuria categories. C, Simulated number of excess composite CV events prevented with finerenone vs placebo per year in US individuals eligible for finerenone with CKD and T2D by KDIGO, eGFR, and albuminuria categories. ^aIndividuals with a UACR of 30 mg/g to less than 300 mg/g were included in NHANES, although 230 patients with UACR less than 30 mg/g were included in FIDELITY because of variability between screening and baseline results. ^bBased on differences of FIDELITY incidence rates between the finerenone and placebo groups. ^cComposite of time to CV death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. ^dData on baseline eGFR and UACR categories were missing for 6 patients in FIDELITY.