eGFR- and Potassium-Guided Stewardship of SGLT2 Inhibitors and Finerenone in Albuminuric Chronic Kidney Disease Associated with Type 2 Diabetes.

Albuminuric chronic kidney disease (CKD) associated with type 2 diabetes remains a high-risk condition despite long-standing renin-angiotensin system (RAS) inhibition. Sodium-glucose cotransporter 2 (SGLT2) inhibitors and finerenone provide complementary kidney and cardiovascular protection through distinct hemodynamic, tubular, inflammatory, and fibrotic mechanisms. The Phase 2, randomized, double-blind Combination Effect of Finerenone and Empagliflozin in Participants with Chronic Kidney Disease and Type 2 Diabetes Using a Urinary Albumin-to-Creatinine Ratio Endpoint (CONFIDENCE) trial subsequently showed that simultaneous finerenone-empagliflozin initiation produced greater short-term albuminuria reduction than either monotherapy, but this biomarker benefit does not establish hard-outcome superiority or define the optimal sequencing strategy. This narrative review proposes a stewardship framework guided by estimated glomerular filtration rate (eGFR) and potassium for adults with albuminuric type 2 diabetes-associated CKD in whom SGLT2 inhibitors and finerenone are being implemented on a RAS-inhibition background. The review emphasizes that kidney protection depends not only on prescribing effective therapies, but also on maintaining exposure through initiation, monitoring, temporary interruption, de-escalation, and re-initiation. A modest early eGFR decline after SGLT2 inhibitor initiation usually reflects a functional hemodynamic response and should not be treated in isolation as drug-related kidney injury. By contrast, finerenone-associated hyperkalemia requires baseline risk stratification, early potassium surveillance, correction of reversible triggers, and structured re-challenge when feasible. Simultaneous initiation may be appropriate in patients with persistent albuminuria, stable eGFR, normal or low-normal potassium, and reliable monitoring access, whereas sequential initiation is often more suitable when potassium risk, hemodynamic instability, or follow-up uncertainty is present. Future studies should move beyond short-term urine albumin-to-creatinine ratio (UACR) lowering to evaluate clinical kidney and cardiovascular outcomes, treatment persistence, potassium-event trajectories, re-initiation after temporary interruption, and implementation fidelity in routine care.