Twenty-Four-Week UACR Response Trajectories and Clinical Correlates of Residual Albuminuria in Diabetic Kidney Disease During Finerenone Therapy: A Real-World Longitudinal Study.

BACKGROUND: After finerenone therapy, some patients with diabetic kidney disease (DKD) continue to have residual albuminuria. A single time-point change in urinary albumin-to-creatinine ratio (UACR) may not fully capture response heterogeneity in real-world practice. This study aimed to identify 24-week baseline-corrected UACR response trajectories in patients with DKD and residual albuminuria during finerenone therapy and to examine associated clinical factors. METHODS: This single-center retrospective real-world longitudinal cohort study included 136 patients with DKD who had residual albuminuria after at least 4 weeks of finerenone therapy and available longitudinal UACR data. Based on multi-time-point log(UACR_t/UACR_baseline) data over 24 weeks, latent class mixed models were used to identify UACR response trajectories and analyze clinical factors associated with the persistent residual albuminuria trajectory. RESULTS: Three UACR response trajectories were identified: favorable response in 43 patients (31.6%), partial response in 62 patients (45.6%), and persistent residual albuminuria in 31 patients (22.8%); the latter 2 patterns accounted for 68.4% of the selected residual-albuminuria cohort. The median relative changes in UACR at week 24 were -51.6%, -24.8%, and -4.9%, respectively. Higher HbA1c was associated with higher estimated odds of the persistent residual albuminuria trajectory (OR, 1.46; 95% CI, 1.07-2.00). The estimated directions for systolic blood pressure and sodium-glucose cotransporter 2 (SGLT2) inhibitor use were consistent, although uncertainty remained in extended or selected sensitivity analyses. Week-24 eGFR changes did not differ clearly across trajectories, and continuous UACR change was not clearly associated with eGFR change. CONCLUSION: Patients with DKD and residual albuminuria during finerenone therapy showed distinct 24-week UACR response trajectories. Trajectory analysis provides exploratory real-world evidence for dynamic risk stratification, but the identified patterns and clinical correlates require validation in larger, prospective, multicenter cohorts with longer follow-up.