Finerenone against placebo in chronic kidney disease with type 2 diabetes: the cardiovascular composite, pooled from the two pivotal trials

Registration and administrative information (PROSPERO field set)

Extracted values, and where each came from

One row per extracted value. Every row carries the value, the verbatim sentence it was read from, a resolvable link to the source, and whether the number was read or derived. Where any of those is absent the row says so rather than omitting the value.

Risk of bias (RoB-2)

Variant:

Unit assessed: —

Assessor 1: (anthropic family). Assessor 2: (openai family).

Overall judgement per trial

Inter-assessor agreement

This assessment is DUAL — two assessors from different model families, the second asked blind. The agreement rate is withheld pending adjudication. Both readers were given this review’s decision rule; an earlier version of this sentence said the blinding had withheld it, and that was wrong. What the 10 domain comparison(s) show is a reading difference that runs in OPPOSITE directions by domain — on domains 1 to 3 the second assessor more often declines to judge at all, and on domains 4 and 5 it more often judges low. A single agreement rate averages those two behaviours into one number that describes neither. Both assessors’ per-result judgements are shown in the table above, unadjudicated, and neither is this review’s finding. No adjudication has been performed, so this review holds no final risk-of-bias judgement for these results.

References

Included studies

• — https://clinicaltrials.gov/study/NCT02540993
• — https://clinicaltrials.gov/study/NCT02545049

Regulatory documents

Methods and guidance

Sources

Visual abstract

⬇ SVG (vector) 2 KB ⬇ PNG 4500x2100 302 KB

All raster formats were generated at build time from the same SVG as the graphic above (SHA-256, first 16 hex characters: f3e570f8aa5e06ce), at 600 dpi for a 6-inch print width, on a white ground. They are not screenshots of the page and do not change with the theme you are reading in.

Submission formats written to the figures directory, not embedded here because an uncompressed 600 dpi TIFF is tens of megabytes: EPS (vector, journal's first choice for line art) — visual-abstract.eps, 4 KB; TIFF (uncompressed, 600 dpi -- journal fallback) — visual-abstract.tiff, 27,685 KB.

Projected from the canonical object, so it carries the same k, the same pooled estimate and the same interval as the paper and cannot drift from them. The interval is drawn to scale against the no-difference line, which it EXCLUDES: 0.788 to 0.951, with no difference at 1.

Risk of bias, both assessors

⬇ SVG (vector) 8 KB

Only the vector format is offered for this figure, by choice: it is line art — discrete marks, glyphs and labels — which SVG reproduces exactly at any size, so a raster would add weight without adding fidelity. The build was able to rasterise; it was asked not to.

Every cell carries BOTH independent cross-family assessments and they are not reconciled: showing one column would be a reconciliation presented as an observation. Glyph as well as colour, so the panel survives greyscale printing and colour-blind reading. A trial with no judgement is shown as a row of not-assessed markers rather than omitted, so a gap in the assessment cannot be mistaken for a clean assessment. Agreement as measured: {'per domain agreed': 9, 'per domain total': 10, 'per domain rate pct': 90.0, 'overall agreed': 0, 'overall total': 2, 'overall is derived': True, 'recomputed from the stored judgements': True, 'why recomputed': 'The stored disagreement tallies were frozen as text and 12 of 22 no longer match the judgements in the object -- a later guidance pass moved 51 the randomisation process judgements and the tallies were never recomputed. This is derived from what the object holds now.'}.

GOSH

⬇ SVG (vector) 1 KB ⬇ PNG 3500x540 81 KB

All raster formats were generated at build time from the same SVG as the graphic above (SHA-256, first 16 hex characters: 9091822e99aa8781), at 600 dpi for a 6-inch print width, on a white ground. They are not screenshots of the page and do not change with the theme you are reading in.

Submission formats written to the figures directory, not embedded here because an uncompressed 600 dpi TIFF is tens of megabytes: EPS (vector, journal's first choice for line art) — gosh.eps, 2 KB; TIFF (uncompressed, 600 dpi -- journal fallback) — gosh.tiff, 5,537 KB.

Deliberately not drawn. Every subset meta-analysis of 2 trials is 3 points; a cloud that small cannot show the multimodality GOSH exists to reveal, and a reader would take the picture as evidence of its absence.

Trial-sequential analysis

⬇ SVG (vector) 1 KB ⬇ PNG 3500x650 87 KB

All raster formats were generated at build time from the same SVG as the graphic above (SHA-256, first 16 hex characters: 25ed9800fdf56614), at 600 dpi for a 6-inch print width, on a white ground. They are not screenshots of the page and do not change with the theme you are reading in.

Submission formats written to the figures directory, not embedded here because an uncompressed 600 dpi TIFF is tens of megabytes: EPS (vector, journal's first choice for line art) — tsa.eps, 2 KB; TIFF (uncompressed, 600 dpi -- journal fallback) — tsa.tiff, 6,665 KB.

TSA boundaries depend entirely on a target information size that must be pre-specified. This review's protocol registers none, so any boundary drawn here would be a parameter chosen after seeing the data -- which is the practice TSA exists to protect against.

Meta-regression

⬇ SVG (vector) 1 KB ⬇ PNG 3500x540 87 KB

All raster formats were generated at build time from the same SVG as the graphic above (SHA-256, first 16 hex characters: e35ec93bbc9a1c10), at 600 dpi for a 6-inch print width, on a white ground. They are not screenshots of the page and do not change with the theme you are reading in.

Submission formats written to the figures directory, not embedded here because an uncompressed 600 dpi TIFF is tens of megabytes: EPS (vector, journal's first choice for line art) — bubble.eps, 2 KB; TIFF (uncompressed, 600 dpi -- journal fallback) — bubble.tiff, 5,537 KB.

The protocol pre-specifies no moderator, and at k = 2 a meta-regression would be fitted on 2 points. Not drawn rather than drawn with a caveat: a bubble plot invites reading a slope, and there is no slope here that any reader should read.

Summary of findings

1. This certainty rating is PENDING, not rated. It rests on a risk-of-bias judgement that this review has not finalised: two assessors read every contributing result independently, they disagree, and no adjudication has been performed, so this review holds no final risk-of-bias judgement for these results. Cochrane rates certainty per outcome by aggregating the risk-of-bias judgements of the results contributing to it, so a certainty rating cannot be more final than the risk-of-bias assessment it reads. The rating this object currently records, and the steps behind it, are shown below as the work so far rather than as this review's answer. No level is published for this outcome -- not the recorded one, not a more cautious one, and not a midpoint -- because choosing one would be the judgement that has not been made.
2. Read this beside `whether the estimand was established`. That flag records that every contributing trial measures the same quantity. It records nothing about what that quantity was measured against -- whether the comparators are of one kind, whether each comparison was randomised, whether it was concurrent. The two questions were never separated. Named as P48 in PAGE-STANDARD.md v1.21.0 and swept by scripts/audit_mixed_contrast_pools.py.

Reproducibility artifact

This page CANNOT be rebuilt from what is recorded here: no canonical object is recorded and no registered commit is recorded. Each figure on the Analysis tab downloads as an SVG carrying exactly the values shown.

Other recorded qualifications

Statements this review records about the limits of what it establishes, which are not shown elsewhere on this page. They are reproduced from the object verbatim and are not summarised.

Paper

Each statement below cites the record it came from; those sources are listed at the end of every section. Where the record holds nothing, the section says so by name rather than being left out, so a procedure that was not carried out can be told from one that simply was never mentioned.

Title

Finerenone against placebo in chronic kidney disease with type 2 diabetes: the cardiovascular composite, pooled from the two pivotal trials¹

Two trial acronyms were transposed and are corrected. This object recorded NCT02545049 as FIDELIO-DKD. It is figaro-dkd. Read from ClinicalTrials.gov API v2 on 2026-08-21: NCT02540993 carries acronym FIDELIO-DKD, NCT02545049 carries acronym FIGARO-DKD. The two trials differ in their registered primary -- FIDELIO-DKD's is the kidney composite, FIGARO-DKD's the cardiovascular one -- so naming them the wrong way round is not a typographical matter: it attributes each trial's design to the other. No estimate moves; the estimates were keyed to the registration numbers, which were right throughout. 2 label(s) corrected.²

Abstract

Question. In adults with chronic kidney disease and type 2 diabetes, does finerenone reduce the first occurrence of the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for heart failure, against placebo?¹

Methods. estimates were pooled under a random-effects model with the REML estimator; risk of bias was assessed with RoB 2 (Cochrane risk-of-bias tool for randomized trials); and certainty was rated with GRADE, following the Cochrane Handbook chapter 14. Randomised evidence starts HIGH and is rated down with reasons.²

Results. First occurrence of the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for heart failure: hazard ratio 0.866 (0.788 to 0.951) across 2 trials; 1 of these pooled outcome(s) carries a stated qualification -- a referral or a recorded finding -- given in full in Results and not reproduced here; and no statistical heterogeneity was detected (I-squared 0%), though heterogeneity cannot be reliably assessed with two trials.³

Introduction

Background. This review asks: In adults with chronic kidney disease and type 2 diabetes, does finerenone reduce the first occurrence of the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for heart failure, against placebo? It pools 2 randomised trials, against placebo. The outcome pooled is First occurrence of the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for heart failure.¹

Methods — search

Primary trials. No bibliographic search for primary trials was run. The 2 included trials were identified by reading named registrations on the dates recorded on each entry. The basis on which this object was verified is not recorded. What this object does not claim is not recorded. The bar this object had to clear is not recorded. Published syntheses. PubMed E-utilities esearch + esummary, executed 2026-08-20. Query as executed: (finerenone[tiab]) and (FIDELIO[tiab] or FIGARO[tiab] or FIDELITY[tiab] OR meta-analysis[pt] OR "systematic review"[pt] OR meta-analysis[tiab] OR "pooled analysis"[tiab]). It matched 252 record(s), of which 252 were retrieved and 252 read; 1 appraised.¹

Methods — eligibility criteria

not recorded on the page this object was extracted from¹

Methods — synthesis

For first occurrence of the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for heart failure, a random model was fitted with the REML estimator.¹

Risk of bias was assessed with RoB 2 (Cochrane risk-of-bias tool for randomized trials) , following . 2 result-level assessments were made.²

A ceiling applies to every risk-of-bias judgement in this review; it is stated with the assessment itself rather than summarised here.³

Certainty of evidence was rated with GRADE, following the Cochrane Handbook chapter 14. Randomised evidence starts HIGH and is rated down with reasons., following . 1 pooled outcome(s) were rated.⁴

Results

The pooled hazard ratio for first occurrence of the composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalisation for heart failure was 0.866 (0.788 to 0.951) across 2 trials, against placebo.¹

Noted on this pool. Read this beside the estimate. FIDELIO-DKD (NCT02540993) registers the kidney composite as its primary outcome and the cardiovascular composite -- the one pooled here -- as the first of five secondaries. FIGARO-DKD (NCT02545049) registers them the other way round. The quantity is identical on both, word for word, so this is a question about which rank was selected and not about what was measured. The unadjusted interval is HR 0.8655 (0.7877 to 0.9510) and excludes no effect. This project's floored Hartung-Knapp interval at k = 2 is 0.4699 to 1.5940 and includes it. At k = 2 the t critical value is 12.7062 and almost nothing survives, so this is weaker evidence against the result than the same crossing would be at larger k. Note that metafor's RAW interval here, 0.8045 to 0.9311, is narrower than the unadjusted one -- which is what the house floor exists to prevent, and it is not cited as ours.²

The trials' results were closely consistent with one another: I-squared, the share of the variation between them that is more than chance alone would produce, was 0%; the estimated variance of the true effects between trials (tau-squared) was 0, the heterogeneity test statistic Q was 0.0143, on degrees of freedom 1. Q = 0.0143 on 1 df: the two trials agree closely, which is what the same endpoint in one programme should look like.³

The grounds for pooling are recorded as: Both trials report the same composite with the same four components in the same order, in CKD with type 2 diabetes, against placebo. Q = 0.0143 on 1 df. Where a later pool on this page rests on the same grounds, they are not restated.⁴

The full model output for every pooled outcome -- the call, the estimator, the heterogeneity statistics and the back-transformed interval -- is stored verbatim on this review object at `results.by_outcome.<outcome>.r_output.verbatim`. It is not reproduced as an Extended data section in this article; an earlier version of this sentence said it was, and no such section exists.⁵

Risk of bias in the included results

Risk of bias was assessed with RoB 2 at the level of each reported result, by two assessors reading independently. Their judgements differ on 2 of the 2 results and no adjudication has been performed, so this review holds no final risk-of-bias judgement for these results. Assessor 1 recorded: 2 at some concerns. Assessor 2 recorded: 2 at no information. Both are shown in the risk-of-bias table; neither is the review's finding. The per-domain judgements behind them are recorded with the extracted data.¹

Certainty of the evidence

Certainty was rated with GRADE, following the Cochrane Handbook chapter 14. Randomised evidence starts HIGH and is rated down with reasons..¹

This certainty rating is pending, not rated. It rests on a risk-of-bias judgement that this review has not finalised: two assessors read every contributing result independently, they disagree, and no adjudication has been performed, so this review holds no final risk-of-bias judgement for these results. Cochrane rates certainty per outcome by aggregating the risk-of-bias judgements of the results contributing to it, so a certainty rating cannot be more final than the risk-of-bias assessment it reads. The rating this object currently records, and the steps behind it, are shown below as the work so far rather than as this review's answer. No level is published for this outcome -- not the recorded one, not a more cautious one, and not a midpoint -- because choosing one would be the judgement that has not been made.²

MODERATE certainty. The two trials agree almost exactly, both are quadruple-masked, and the pooled composite is defined identically on both registrations -- so the single downgrade is for the unread deviation and missing-data domains and for the pooled result being FIDELIO's registered secondary rather than its primary.³

Where a result is rated worse than LOW overall, the domain carrying that judgement is: selection of the reported result on 1 result(s). The overall rating is the worst domain, so these are the domains that determine it.⁴

Comparison with published syntheses

Published syntheses were identified as follows. PubMed E-utilities, executed 2026-08-20. Query, counts and per-record disposition in ssot/finerenone-cv/appraisal/the screen of published syntheses.json.¹

Limitations

What this review does not give a clinician: the number of events in each arm, any absolute effect or number needed to treat and any measure of harm. A relative effect cannot be turned into the benefit or the risk facing one patient without them, so this review can support a judgement about what these trials found and not a judgement about what to do.¹

Data availability

The underlying records are the 2 source(s) listed under References; each names the layer it was read at, so a reader can tell a registry record from a published report.¹

Software availability

Analyses were computed under R 4.6.0 with metafor 5.0.1.¹

Note on registration

No PROSPERO registration or protocol record is held on this object. That is not the same as knowing this review was not registered, and neither claim is made. It is recorded here as an absence so that a reader does not have to infer it from silence.¹

References

Figures

Trial characteristics

Not reported in this record

The items below were not written because the record does not hold what they would be composed from. They are named here so that an absence is not mistaken for an omission.