UACR Screening and Finerenone Safety in Diabetic CKD

Annual urine albumin-to-creatinine ratio (UACR) testing is recommended for every person with diabetes, yet completion in primary care remains low. The gap leaves early chronic kidney disease (CKD) undetected at the stage when intervention offers the greatest benefit.

On a recent episode of Diabetes Dialogue, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, examined screening barriers and prescribing considerations surrounding finerenone (Kerendia), the nonsteroidal mineralocorticoid receptor antagonist (MRA) recently approved for CKD associated with type 1 diabetes.1

Watch the full episode discussing finerenone’s new approval here.

Assessments of primary care clinics place annual UACR completion near 20% among patients with diabetes. Missed tests reflect more than ordering lapses, because some patients hesitate to complete a urine test when its purpose goes unexplained. Framing UACR like a mammogram or colonoscopy, as early detection offering more options before disease progresses, may improve adherence.

Patients also benefit from hearing how glycemic control alone will not prevent kidney disease, particularly with coexisting hypertension or dyslipidemia. Explaining the rationale behind each screening test tends to build buy-in, even amid crowded clinic schedules and inbox demands.

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) remain first-line for albuminuria, with titration to the maximum tolerated dose. These inexpensive agents form the foundation, and finerenone adds renoprotection on top of them. Because ACE inhibitors, ARBs, and finerenone all raise serum potassium, monitoring becomes essential as therapies are layered.

Resistant hypertension introduces another consideration. Spironolactone, a steroidal MRA, shares a target with finerenone, although the nonsteroidal agent carries a more favorable adverse effect profile. The two should never be combined, mirroring the rule against pairing an ACE inhibitor with an ARB.

For patients already taking spironolactone, starting finerenone calls for reassessing the blood pressure regimen and substituting a different antihypertensive. Clinicians switching between ACE inhibitors and ARBs for cough or inadequate response follow the same logic of choosing one agent per pathway.

Collectively, these considerations position finerenone as an addition to established renin-angiotensin blockade rather than a replacement. Its real-world impact in diabetes will depend on earlier CKD detection through consistent UACR screening and disciplined management of hyperkalemia risk.

Editors’ Note: Isaacs reports disclosures with Dexcom, Abbott, Lilly, Novo Nordisk, Medtronic, Insulet, and others. Bellini reports disclosures with Abbott Diabetes Care, MannKind, Povention Bio, and others.

References

1. Bayer. Bayer’s KERENDIA (finerenone) Receives FDA Approval as the First New Treatment in 30 Years for Adults with Chronic Kidney Disease (CKD) and Type 1 Diabetes. September 17, 2026. Accessed September 18, 2026. https://www.bayer.com/en/us/news-stories/treatment-forchronic-kidney-disease-and-type-1-diabetes