"Hi, I am Beatrice Fernandez Fernandez. I am medical doctor, nephrologist in Fundacion Jimenez Diaz in Madrid, Spain. And today I am going to talk about a new real evidence of using finerenone in Madrid community in Spain.

Finerenone was commercially available in Spain on 15th of May 2024. So we started using finerenone following KDIGO guidelines. But instead there are lots of patients that are under steroidal mineral receptor antagonists which use esteroidal mineral receptor antagonists for decreasing albuminuria in this population. So what we wanted to know was what's happening if we are switching steroid aminoreceptor antagonists for non steroid aminoreceptor antagonists in type 2 diabetic population? Because type 2 diabetes is the main reason for going to dialysis in Spanish population. And we really want to get rid of this situation.

So we designed a multicentre study in Madrid community. And we did that within the umbrella of SOMANE, which is the Spanish the Madrian Society of Nephrology. We sent a letter to the hospitals, they answered yes. And then we did a retrospective analysis.

What we found was that of course it was safe in the total population. There was something very nice in our study because we started finerenone with 10 milligrammes in most of the patients. Nephrologists are very, very aware of all the complications all our patients can have. Decreasing egfr, increasing potassium, having a lot of different complications due to uremic environment. So we were not very confident to start finerenone up to 20 milligrammes. So most of the patients, 90% of the patients started finerenone just with 10 milligrammes independently of the EGFR.

And what we found in three months was that in the total population potassium was quite okay, that increased a little bit. 1.2, 0.5 milligrammes milliequivalents per litre and the EGFR decreased just a little bit, not significant. But albuminria in the global population decreased more than 200 milligrammes per gramme.

So then we extracted this part of the population we really wanted. What happened about the switching from one to the other one from steroidal to non steroidal. So then what we found in that specific population there were just 24 patients, okay? And in that population we found very nice results. Decreasing potassium. Those patients switching from steroidal to non steroidal significantly decreased the potassium. They had almost 5 milliequivalents per litre of potassium. And they decreased 0.5 milliequivalents per litre of potassium. That means you can be like relaxed when using nonsteroidal. Comparing that when you are using steroid amino receptor antagonists, what happened to the EGFR serum creatinine? EGFR was maintained. So it is exactly the same in terms of safety and in terms of decreasing egfr. And albuminuria was maintained. That means like it's equally important but with less secondary effects.

No one left the medication, no one said anything about any different issues on a medication. And then it's a dual thing. People were more happy because they got rid of the secondary effects of that medication. And we also did that in the regular daily basis. That means we don't have time for longer washout periods in between taking one medication and taking the other one. We just have to be fast. And we had like from 24 maybe to 72 hours without steroid aminoreceptor antagonist and then the patient started directly. Not steroid aminoreceptor antagonist finerenone No hyperkalemia effects, no problems.

So switching from one medication to the other medication is safer. We can just be we can just have the blood samples longer in time because sometimes when we are using serotoninoreceptor antagonist we get some stress and we have to take like potassium and one month after potassium and in summer or whatever. But then when we use non steroid aminoreceptor antagonist we will be more relaxed because the patient decreased serum potassium and will be like more time with the, with the, with the right combination. And then what's even more, those patients combining SGLT2 inhibitors and steroid, non steroid aminoreceptor antagonist had even lower serum potassium levels, which is totally presumable as we've seen in confidence trial. But in the regular, in the daily clinical basis you can confirm what you've seen in the randomised clinical trials. And this is a very, very good thing for doctors. And the most important thing, this is a very good thing for patients with chronic kidney disease.

So the impact on clinical practice is here quite clear. If you change for steroid aminoreceptor antagonist to non steroid aminoreceptor antagonist, potassium is going to get lower, it's going to get better. So then there's no need to increase other medications such as potassium minus, you will be confident of using nonsteroidal minerocorticoid receptor antagonist for lowering albuminuria because they will be mostly the same of using steroidal amino receptor antagonist.

This is something doctors were very much aware of. There were many, many, of us of nephrologists that were concerned because steroid aminoreceptor antagonists are highly potent for decreasing albuminuria. So we didn't know if finerenone was going to be equally potent for decreasing albuminuria. But now we know that it's equally potent for decreasing albuminuria, with lower effects on potassium, with nice effects and on serum creatinine or eGFR. That means that it won't decrease your eGFR. Your eGFR will be stable. And if the patient's got higher serum potassium, you can just switch from one medication to the other one, mostly directly without needing a washout period. Because in this washout period of 4, 6, 3 weeks, the patient is without the medication. And if the patient is without the medication, this risk will increase, this albuminuria will increase. And you don't really want this albuminuria to increase. You want that to remain stable. So you can be sure that switching directly will be good for your patient and you won't have like, problems or secondary effects.

I think we have to do more patients. So we need more and more patients included. I don't think there will be a face to face comparison. I think the comparison will be from the nephrologist. It's in our hands. In Spain we're going to open that, Spanish Society of Nephrology because we've seen that results are good. So if we can include more patients, if we can include more patients in the real daily settings, we can be more confident of opening that to the whole population.

And moreover, now we are using that in type 2 diabetes patient. But this is like the base we are going to go up and we are going to use finerenone not only for diabetic patients. We've seen that nice results. We're going to use it for non diabetic patients. We're going to use it for these patients with albuminuria that are under steroidal mineralocorticoid receptor antagonist. Because we didn't have anything else to offer and now we've got something more to offer.

So I think the future comes from very big data sets, very big databases, and from the feelings of the nephrologists for adding more and more patients to these big data sets, these databases. So, as to be sure that what we found is plausible, we can use that in the real life and open that and spread the message to the rest of the world.”