Network meta-analysis: SGLT2 inhibitors versus finerenone in CKD with type 2 diabetes

The study

No randomised trial has compared SGLT2 inhibitors directly with finerenone in chronic kidney disease (CKD) with type 2 diabetes. The authors therefore ran a systematic review and network meta-analysis, published in Diabetes, Obesity & Metabolism.

They searched MEDLINE, Embase, CENTRAL and trial registries from inception to August 2026 for placebo-controlled outcome trials. Hazard ratios (HRs) were pooled in a frequentist random-effects model. The comparison between the two classes was derived indirectly, through placebo. Risk of bias was judged with RoB 2 and certainty with CINeMA. The review is registered as CRD420261439899.

Ten trial datasets formed a star network without closed loops. The abstract does not report the number of patients, the names of the trials, or funding.

What they found

Versus placebo, both classes reduced kidney function progression:

• SGLT2 inhibitors: HR 0.64 (95% CI: 0.56-0.73)
• Finerenone: HR 0.84 (95% CI: 0.77-0.92)

Both also reduced heart-failure hospitalisation:

• SGLT2 inhibitors: HR 0.61 (95% CI: 0.53-0.69)
• Finerenone: HR 0.78 (95% CI: 0.66-0.92)

In the indirect comparison, SGLT2 inhibitors were favoured for kidney function progression (HR 0.76, 95% CI: 0.64-0.90) and for heart-failure hospitalisation (HR 0.77, 95% CI: 0.63-0.95). For atherothrombotic events and mortality, the two classes were not significantly different.

The authors ran further analyses. The kidney contrast remained significant after they excluded datasets at high risk of bias, after they restricted the analysis to dedicated CKD trials, and after they applied a uniform endpoint. The heart-failure contrast did not persist in dedicated CKD trials.

For safety, finerenone increased hyperkalaemia without increasing acute kidney injury. The authors note that safety domains are not reported comparably across the two classes.

How much weight to give it

The authors rated certainty as low or very low for every between-class comparison. They describe the differences favouring SGLT2 inhibitors as hypothesis-generating and say they should not be used to rank the agents.

The reasons lie in the design. The network has no closed loops, so the indirect result cannot be checked against any direct comparison. The authors also say transitivity cannot be verified. This means it is not known whether the trial populations were similar enough for an indirect comparison to be fair.

The comparisons against placebo are more direct than the between-class contrast. Even so, the abstract does not give a certainty rating for them, so the full paper should be checked.

For your clinic

This analysis supports the view that both SGLT2 inhibitors and finerenone offer cardiorenal protection in CKD with type 2 diabetes. The authors conclude that the two classes appear complementary rather than interchangeable.

The authors state that the indirect differences favouring SGLT2 inhibitors are hypothesis-generating and should not be used to rank the agents. The heart-failure contrast also did not persist in dedicated CKD trials.

The abstract does not examine using both classes together, so it cannot guide combination use. Clinics that use finerenone should note the higher hyperkalaemia signal reported here. Read the full paper and current guidelines before changing any local protocol.