Abstract
<title>Abstract</title> <p> Background Finerenone, a selective nonsteroidal mineralocorticoid receptor antagonist (MRAs), has demonstrated cardiorenal benefits in patients with diabetic kidney disease (DKD). However, evidence regarding its effectiveness and safety in non-diabetic chronic kidney disease (non-DKD) still remains limited. This study was designed to evaluate the real-world efficacy and safety of finerenone in non-DKD and compare its performance with other treatment strategies. Methods We conducted a single-center, retrospective cohort study including 281 patients with chronic kidney disease from August 2023 to June 2025. Patients were categorized into three groups: non-diabetic CKD treated with finerenone (nonDKDF, n = 151), DKD treated with finerenone (DKDF, n = 65), and non-DKD treated with renin–angiotensin system inhibitors plus SGLT-2 inhibitors (nonDKDAS, n = 65). Primary outcomes included changes in urinary albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), serum potassium, and systolic blood pressure (SBP) over 12 months. Subgroup analyses were performed based on glomerular disease pathology. Results Patients in the nonDKDF group showed significantly greater reductions in UACR compared to both DKDF and nonDKDAS groups at all time points, particularly at 6 month time ( <italic>P</italic> < 0.01). Renal function remained stable in the nonDKDF group, while eGFR declined in the comparator groups. Serum potassium levels remained within the safe range in all groups. In membranous nephropathy, finerenone exhibited the most pronounced antiproteinuric response, and multivariable regression analysis showed that membranous nephropathy is an independent risk factor for UACR decline ( <italic>β</italic> = − 947.6, <italic>P</italic> = 0.019). No serious adverse events related to hyperkalemia or hypotension were found. Conclusion Finerenone demonstrated favorable efficacy and safety in patients with non-diabetic CKD, particularly in those with membranous nephropathy. These findings support its potential role as an adjunctive therapy in glomerular diseases with persistent proteinuria beyond diabetic populations. </p>