Comparative Cardiorenal Efficacy and Safety of SGLT2 Inhibitors and Finerenone in Chronic Kidney Disease With Type 2 Diabetes: A Systematic Review and Network Meta‐Analysis

Abstract

ABSTRACT Aims No randomized trial has compared SGLT2 inhibitors with finerenone in chronic kidney disease (CKD) with Type 2 diabetes. We estimated their comparative cardiorenal efficacy and safety. Materials and Methods MEDLINE, Embase, CENTRAL and trial registries were searched from inception to August 2026 for placebo‐controlled outcome trials. Hazard ratios (HRs) were pooled in a frequentist random‐effects network meta‐analysis, and the between‐class contrast was derived indirectly through placebo. Risk of bias followed RoB 2 and certainty followed CINeMA. Results Ten trial datasets formed a star network without closed loops. Versus placebo, both classes reduced kidney function progression (SGLT2 inhibitors HR: 0.64, 95% CI: 0.56–0.73; finerenone 0.84, 0.77–0.92) and heart‐failure hospitalization (0.61, 0.53–0.69; 0.78, 0.66–0.92). Indirectly, SGLT2 inhibitors were favoured for kidney function progression (0.76, 0.64–0.90) and heart‐failure hospitalization (0.77, 0.63–0.95), with no significant difference for atherothrombotic events or mortality. The kidney contrast remained significant after excluding high‐risk‐of‐bias datasets, restricting to dedicated CKD trials and applying a uniform endpoint; the heart‐failure contrast did not persist in dedicated CKD trials. Finerenone increased hyperkalemia without increasing acute kidney injury. Certainty was low or very low for every between‐class comparison. Conclusions SGLT2 inhibitors and finerenone both provide cardiorenal protection and appear complementary rather than interchangeable. Indirect differences favouring SGLT2 inhibitors derive from a loop‐free network with unverifiable transitivity and low certainty; they are hypothesis‐generating and should not be used to rank the agents. Safety domains are not reported comparably across classes. Trial Registration CRD420261439899