Abstract Body (Do not enter title and authors here): Introduction
Finerenone is a selective non-steroidal mineralocorticoid receptor antagonist (MRA) approved by FDA in 2021 for reducing the progression of albuminuria in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus. The FINEARTS-HF trial reported cardiovascular benefits in patients with heart failure with mildly reduced or preserved ejection fraction. However, limited data exist comparing steroidal MRA with finerenone in patients with heart failure with reduced ejection fraction (HFrEF) and CKD.

Methods
We conducted a retrospective cohort study using Trinet X Global collaborative network from August 2021 to December 2024, including patients aged >18 years with HFrEF and CKD. Patients treated with finerenone were propensity-matched 1:1 to those receiving either spironolactone or eplerenone. Outcomes of interest, assessed over a three-year follow-up period, included all-cause mortality, heart failure exacerbation, acute myocardial infarction (MI), atrial fibrillation, cerebrovascular accident (CVA), acute kidney injury (AKI), hyperkalemia, need for intravenous diuresis, new dialysis initiation, and major adverse cardiac events (MACE is a composite of all-cause mortality, HF exacerbation, MI, and CVA).

Results
A total of 402 patients with an average age of 70 years, 65% males and 43% white. Steroidal MRA had a lower risk for new need for IV diuresis (HR: 1.63, 95% CI; 1.1 – 2.5, p = 0.026). There was no statistically significant difference in acute kidney injury (HR: 1.18, 95% CI; 0.84 – 1.64, p = 0.34), hyperkalemia (HR:0.89, 95% CI; 0.63 – 1.26, p = 0.52), initiation of dialysis (HR: 1.5, 95% CI; 0.8 – 2.8, p = 0.2), heart failure exacerbation (HR: 0.93, 95% CI; 0.6– 1.4, p = 0.73), acute myocardial infarction (HR: 1.3, 95% CI; 0.8 – 2.1, p = 0.2), atrial fibrillation (HR: 1.2, 95% CI; 0.8 – 1.9, p = 0.34), cerebrovascular accident (HR: 0.7, 95% CI; 0.3 – 1.3, p = 0.25) and MACE (HR: 0.7, 95% CI; 0.4 – 1.0, p = 0.06) between finerenone and steroidal MRA groups. The number of deaths in each group was fewer than ten, which limited the ability to report exact all-cause mortality events.

Conclusion
In this real-world analysis of patients with HFrEF and CKD, we found that finerenone demonstrated a comparable cardio-renal safety and effectiveness profile to steroidal MRAs. Patients receiving finerenone had a higher risk of requiring intravenous diuresis, which may suggest differences in fluid management compared to steroidal MRAs.