Alper Tuna Güven, Serap Yadigar, Murat Özdede, Suat Akgür, Felemez Arslan, Mehmet Sezen, Büşra Özcan, Elif Yıldırım Ayaz, Betül Doğantekin, İlker Atay, Serpil Müge Değer, Mustafa Demir, Sümeyra Koyuncu, Üstün Yılmaz, Ayça İnci, Hülya Çolak, Bülent Demirelli, Serhan Tuğlular, Ebru Gok Oguz, Mehmet Deniz Ayli, Ezgi Avanaz, Fatih Yılmaz, Beyza Doğan, Süleyman Karaköse, Mine Şebnem Karakan, Bahar Gürlek Demirci, Kültigin Türkmen, İsmail Baloğlu, Mehmet Batmazoğlu, Mehmet Mert, Emre Aydın, Fatma Yılmaz Aydın, Ergün Parmaksız, Pınar Özdemir, Bartu Ediz, Zeki Aydın, Mehmet Emin Demir, Siren Sezer, Suat Ünver, Öznur Baykal, Beril Akman, Atila Altuntaş, Mahmud İslam, Sibel Yücel Koçak, Meral Mert, Belda Dursun, Necmi Eren, Simge Bardak Demir, Mukadder Ayşe Bilgiç, Arda Erdut, Gülşah Keskin, Mehmet Horoz, Ahmet Ziya Şahin, Merve Tekinyıldız, Murat Duranay, Serkan Feyyaz Yalın, Hazal Melike Yavuz Umut, Murat Altunok, Ramazan Sarı, Funda Sarı, Dilek Torun, Serdar Kahvecioğlu, Asena Serap Karatutlu, Tülin Akagün, Hüseyin Çelik, Sinan Kazan, İlyas Öztürk, Mehmet Polat, Mehmet Fethullah Aydın, Meral Meşe, Asil Demirezen, Ülver Derici, Eda Altun, Serkan Bakırdöğen, Ekrem Kara, Cüneyt Akgöl, Mahmut Başar Aykent, Ali İlter, Ahmet Ekmekci, Sena Ulu, Mustafa Arıcı, Erkan Şengül, Elif Arı Bakır
Background/Objectives: Finerenone improves cardiovascular and renal outcomes in diabetic kidney disease (DKD), but hyperkalemia remains a key safety concern. Patients with elevated baseline potassium levels (≥4.9 mEq/L) are largely excluded from clinical trials, and real-world data in this population are scarce. Methods: In this retrospective multicenter cohort study derived from the FINE-TURK cohort, adults with DKD who initiated finerenone with baseline potassium ≥ 4.9 mEq/L were included. The primary outcome was clinically significant hyperkalemia (K ≥ 5.5 mEq/L) within three months. Multivariable logistic regression analyses were used to identify associated factors, with multiple sensitivity analyses performed. Results: A total of 166 patients were included, of whom 47 (28.3%) had baseline potassium levels between 5.1 and 5.5 mEq/L. Of the 166 patients, 35 (21.1%) reached the primary outcome, and 10 (6%) patients had follow-up potassium ≥ 6.0 mEq/L. 126 (76.8%) patients required no intervention, 24 (14.6%) were initiated on potassium binders, and finerenone was discontinued in only 12 (7.3%) patients. Lower baseline estimated glomerular filtration rate, baseline urinary albumin, loop diuretic use and 20 mg finerenone dose were associated with the primary outcome. In contrast, baseline potassium was not associated with the primary outcome. Conclusions: In patients with DKD and elevated baseline potassium levels, finerenone initiation was associated with manageable rates of hyperkalemia. Our findings support the cautious use of finerenone in selected patients under close monitoring, as well as highlight the need for a multidimensional approach to hyperkalemia risk assessment.