Comparative Cardiorenal Efficacy and Safety of SGLT2 Inhibitors and Finerenone in Chronic Kidney Disease With Type 2 Diabetes: A Systematic Review and Network Meta-Analysis

AIMS: No randomized trial has compared SGLT2 inhibitors with finerenone in chronic kidney disease (CKD) with Type 2 diabetes. We estimated their comparative cardiorenal efficacy and safety. MATERIALS AND METHODS: MEDLINE, Embase, CENTRAL and trial registries were searched from inception to August 2026 for placebo-controlled outcome trials. Hazard ratios (HRs) were pooled in a frequentist random-effects network meta-analysis, and the between-class contrast was derived indirectly through placebo. Risk of bias followed RoB 2 and certainty followed CINeMA. RESULTS: Ten trial datasets formed a star network without closed loops. Versus placebo, both classes reduced kidney function progression (SGLT2 inhibitors HR: 0.64, 95% CI: 0.56-0.73; finerenone 0.84, 0.77-0.92) and heart-failure hospitalization (0.61, 0.53-0.69; 0.78, 0.66-0.92). Indirectly, SGLT2 inhibitors were favoured for kidney function progression (0.76, 0.64-0.90) and heart-failure hospitalization (0.77, 0.63-0.95), with no significant difference for atherothrombotic events or mortality. The kidney contrast remained significant after excluding high-risk-of-bias datasets, restricting to dedicated CKD trials and applying a uniform endpoint; the heart-failure contrast did not persist in dedicated CKD trials. Finerenone increased hyperkalemia without increasing acute kidney injury. Certainty was low or very low for every between-class comparison. CONCLUSIONS: SGLT2 inhibitors and finerenone both provide cardiorenal protection and appear complementary rather than interchangeable. Indirect differences favouring SGLT2 inhibitors derive from a loop-free network with unverifiable transitivity and low certainty; they are hypothesis-generating and should not be used to rank the agents. Safety domains are not reported comparably across classes. TRIAL REGISTRATION: CRD420261439899.