Would you recommend starting finerenone for a patient with diabetic kidney disease who has marked improvement from severely increased albuminuria to moderately increased albuminuria following ARB and SGLT2i initiation?

Yes, if the potassium and blood pressure allow it. The real question is whether there is an added benefit from finerenone compared to spironolactone. My personal belief is no, except that finerenone is much less likely to cause hyperkalemia.

I would certainly discuss with the patient regarding potential benefits as well as risks. This is a joint decision matter, especially if finerenone leads to the need for potassium binders. Make sure first that the ARB dose is maximized with appropriate use of a diuretic.