Comparative effectiveness of finerenone versus steroidal mineralocorticoid receptor antagonists on sepsis-induced cardiomyopathy in patients with diabetic kidney disease: a real-world cohort study.

Background: Sepsis-induced cardiomyopathy (SICM) is a common but underrecognized complication of sepsis and is associated with adverse short- and long-term outcomes. Patients with diabetic kidney disease (DKD) are particularly vulnerable to sepsis-related cardiac dysfunction, potentially due to chronic inflammation and heightened mineralocorticoid receptor (MR) activation. Whether non-steroidal MRAs are associated with a lower risk of SICM compared with steroidal MRAs remains unknown. Methods: Using the TriNetX federated electronic health record network, we conducted a retrospective cohort study of adults with DKD and sepsis between 2021 and 2025. Patients initiating finerenone were compared with those initiating steroidal MRAs. Propensity score matching (1:1) was performed to balance baseline characteristics. The primary outcome was SICM, defined by heart failure, cardiogenic shock, pulmonary edema, or left ventricular ejection fraction ≤50%. Secondary outcomes included all-cause mortality and surrogate markers of myocardial injury. Cox proportional hazards models were used to estimate hazard ratios (HRs). Results: After matching, 1,378 patients were included in each group. Finerenone use was associated with a significantly lower risk of SICM compared with steroidal MRAs (3.3% vs 5.2%; HR 0.59, 95% CI 0.40-0.87). Finerenone was also associated with lower all-cause mortality (HR 0.45, 95% CI 0.31-0.65) and a reduced risk of surrogate myocardial injury outcomes (HR 0.48, 95% CI 0.25-0.90). Results were generally directionally similar across several subgroup analyses, although the association was attenuated among patients not receiving SGLT2 inhibitors. Conclusion: In this real-world cohort of patients with DKD and sepsis, finerenone use was associated with a lower observed risk of clinically recognized SICM compared with steroidal MRAs. A lower all-cause mortality rate was also observed; however, given the magnitude of this association and the observational design, this finding should be interpreted cautiously and may reflect residual confounding or treatment-selection bias. These findings are hypothesis-generating and require confirmation in prospective studies.