Inside FIND-CKD: Can Finerenone Pair With Immunosuppression in GN?

This is a deep dive into one segment of a recent episode of Kidney Compass: Navigating Clinical Trials, HCPLive's podcast co-hosted by Shikha Wadhwani, MD, and Brendan Neuen, MBBS, PhD. In this episode, Neuen steps out of his usual co-host role to join as a guest, discussing the FIND-CKD trial results he presented at the European Renal Association (ERA) Congress.

Finerenone, a nonsteroidal mineralocorticoid receptor antagonist (MRA), doesn't target the immune mechanisms driving glomerulonephritis (GN) and according to Brendan Neuen, MBBS, PhD, that's exactly the point. The FIND-CKD trial excluded patients treated with immunosuppression in the 6 months prior to enrollment, a design choice Neuen said reflected the conservatism of the trial's 2020 design rather than a signal against combining the two treatment approaches.

"We're not reducing Gd-IgA1 with finerenone," Brendan Neuen, MBBS, PhD, told HCPLive. "That's not the point of the drug."

Why FIND-CKD Excluded Recent Immunosuppression

"We weren't necessarily surprised that the treatment effect was consistent across, regardless of the type of kidney disease," Neuen said. "We know that mineralocorticoid receptor antagonism is a final common pathway across many forms of kidney disease, and so if you think about it that way, it's not surprising that the benefits are there across different forms of kidney disease, including GN."

Neuen said the immunosuppression exclusion criterion was a product of its era. "This was back in 2020, as I like to remind people, before DAPA-CKD," he said. "If we'd done it again, perhaps I would. I mean, we would have liked to, and I think we're being much more inclusive with kidney outcome trials now."

A More Inclusive Approach in Current Trial Design

Neuen described how his approach to eligibility criteria has shifted in trials he has since been involved in. "If people have a kidney disease requiring immunological therapy, so long as that treatment is stable, and investigators don't anticipate a relapse or something else, then it's worth including those patients in, because it allows us to be more inclusive and our results are more generalizable," he said.

He noted the tradeoff cuts both ways. "If you do include a group like that in whom the treatment might not work and that muddies the overall result, then we're not really advancing care for anyone. So it's a fine balance to walk," Neuen said.

The Case for Combining Finerenone With Immunosuppressive Therapy

From a mechanistic standpoint, Neuen sees no barrier to using finerenone alongside immunological treatment. "If you just think about the way that our drugs work, and what guidelines say, you know, KDIGO for IgA nephropathy: target the underlying immunological problem and the downstream consequences of IgA-mediated nephron loss," he said. "I see no reason why we shouldn't be doing these together simultaneously with a SGLT2 inhibitor and an MRA, because they're targeting completely different pathways and complementary pathways."

Neuen's framing aligns with the 2025 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Management of IgA Nephropathy (IgAN), which explicitly recommends combining anti-inflammatory and antifibrotic agents with therapies that target IgA immune-complex formation. The guideline notes that the optimal sequencing of these combinations still needs to be established through trials, a gap Neuen's comments suggest FIND-CKD and future analyses are beginning to address.

Neuen said forthcoming data will help clarify how finerenone exerts its protective effect in IgA nephropathy specifically. "Later this year, at another meeting, I'll be presenting some of the data specifically in the IgAN cohort, helping us to understand how finerenone is exerting its kidney disease protective effects," he said. "No surprises: it's probably not targeting the immunological aspect of the disease."

Layering and Sequencing as the Next Frontier

Neuen framed the immunological and non-immunological pathways as complementary rather than competing. "The point of the drug is to address the common final pathways that are not unique to IgAN, but all forms of kidney disease, and we can do that in parallel with disease-modifying therapies now," he said.

He pointed to layering and sequencing as an emerging area of focus. "I think that is the really exciting part of this whole conversation, which is how do we layer these therapies, how do we sequence them," Neuen said, adding that the topic warrants further discussion beyond this conversation.

Editors' Note: Disclosures for Wadhwani include Boehringer Ingelheim, Calliditas Therapeutics, GSK, Otsuka Pharmaceutical Co., Travere Therapeutics, and others. Disclosures for Neuen include AstraZeneca, Bayer, Boehringer Ingelheim, Janssen, and others.

References

1. Heerspink HJL, Neuen BL, Agarwal R, et al. Finerenone in persons with chronic kidney disease without diabetes. N Engl J Med. 2026. doi:10.1056/NEJMoa2604625

2. Floege J, Barratt J, Cook HT, et al. Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV). Kidney Int. 2025.